electronic submission of Medical Documentation (esMD)

Determination of Coverage (eDoC) Workgroup

Kick-Off of

Structured Data Sub-Workgroup

March 1, 2013

Welcome and Introductions

DAN KALWA

Health Insurance Specialist,

CMS / OFM / Provider Compliance Group

ROBERT DIETERLE

esMD Initiative Coordinator

VIET NGUYEN, MD

Sub-Working Group Lead

Chief Medical Information Officer

Systems Made Simple, Inc.

MARK D PILLEY, MD AAFP, AADEP, ABQAURP

Medical Director

StrategicHealthSolutions, LLC

MICHAEL HANDRIGAN, MD

Medical Officer

CMS / OFM / Provider Compliance Group

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Agenda

Purpose/Goals

Proposed Process

Timeline and Summary

Challenges

Community Participation

Questions

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SWG Goals

• Define a reusable process by which Payors can define and standardize the data they need to perform a DoC

• Identify and apply standards to data utilized in the DoC process - PMD Use Case

• Create a set of artifacts (e.g. CDA template) that can be utilized by Implementers

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SWG Process• Define EXISTING business processes/rules and data

requirements in the DoC• Identify and enumerate existing data capture artifacts for

PMD• Identify and enumerate data elements• Determine if data element is best represented by

narrative or codes• Evaluate and apply existing standards• Create artifacts to support implementation

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BUSINESS PROCESSES

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eDoC General Workflow

Payer

Patient

LCMPSpecialist /Service Provider

Physician

Templates and Rules

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Visits Physician/ PractitionerB

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Documents the F2F visit in progress note in medical record. Must include: - Purpose of the visit is to document

the need for a PMD - Exam findings

Writes 7-element order

Completes Detailed Product Description

Signs/Dates Detailed Product Description

Receives/Files Signed/Dated Detailed Product Description

Receives/Files F2F visit progress note and order

Submits Documentation Package including:• F2F note• 7-Element Order• Detailed Product Description• Other Supporting Documentation

Request Process for PMD

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Licensed/Certified Medical Professional (LCMP) (PT/OT) Role in Face-to-Face Process

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MP

Visits Physician/ Practitioner

Documents the F2F visit in medical record

Must include:- Send for LCMP evaluation

Writes order for LCMP evaluation

Documents the Mobility Evaluation in medical record

Reviews, states concurrence, signs and dates LCMP evaluation

Visits LCMP for Evaluation

Writes 7-element order

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EXISTING DATA CAPTURE ARTIFACTS AND DATA ELEMENTS

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CMS PMD Clinical Template

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Seven Element Order

1. Patient’s name,

2. Description of item ordered (description may be general [e.g., “power operated vehicle”, “power wheelchair”, or “power mobility device”] or more specific),

3. Date of face-to-face examination,

4. Pertinent diagnoses/conditions that relate to the need for a PMD,

5. Length of need,

6. Physician’s signature, and

7. Date of physician’s signature.

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Evaluate Existing Standards

• Consolidated Clinical Document Architecture (C-CDA)• Predefined and HL7 approved• Documents, Sections and Elements

• Standard Coding Systems• SNOMED• LOINC• ICD

• Standard Evaluation Terminology• International Classification of Functionality

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Consolidated CDA Document Types• Continuity of Care Document 1.1• History and Physical• Consult Note• Discharge Summary• Diagnostic Imaging Report• Procedure Note• Operative Note• Progress Note• Unstructured Document

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C-CDA – History and PhysicalAllergies Section (entries optional)

Assessment and Plan Section

Assessment Section

Chief Complaint and Reason for Visit Section

Chief Complaint Section

Family History Section

General Status Section

History of Past Illness Section

History of Present Illness Section

Immunizations Section (entries optional)

Instructions Section

Medications Section (entries optional)

Physical Exam Section

Plan of Care Section

Problem Section (entries optional)

Procedures Section (entries optional)

Reason for Visit Section

Results Section (entries optional)

Review of Systems Section

Social History Section

Vital Signs Section (entries optional)

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Sample C-CDA SectionHistory of Past Illness

This section describes the history related to the patient’s past complaints, problems, or diagnoses. It records these details up until, and possibly pertinent to, the patient’s current complaint or reason for seeking medical care.

1. SHALL contain exactly one [1..1] templateId (CONF:7828) such that it

a. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.20" (CONF:10390).

2. SHALL contain exactly one [1..1] code (CONF:15474).

a. This code SHALL contain exactly one [1..1] @code="11348-0" History of Past Illness (CodeSystem: LOINC 2.16.840.1.113883.6.1 STATIC) (CONF:15475).

3. SHALL contain exactly one [1..1] title (CONF:7830).

4. SHALL contain exactly one [1..1] text (CONF:7831).

5. MAY contain zero or more [0..*] entry (CONF:8791) such that it

a. SHALL contain exactly one [1..1] Problem Observation (templateId:2.16.840.1.113883.10.20.22.4.4) (CONF:15476).

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Sample C-CDA Entry

PROBLEM OBSERVATION

…

SHALL contain exactly one [1..1] value with @xsi:type="CD", where the @code SHOULD be selected from ValueSet Problem Value Set 2.16.840.1.113883.3.88.12.3221.7.4 DYNAMIC (CONF:9058).– This value MAY contain zero or more [0..*] translation

(CONF:16749).• The translation, if present, MAY contain zero or one [0..1] @code

(CodeSystem: ICD10CM 2.16.840.1.113883.6.90 STATIC) (CONF:16750).

…

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ValueSet Problem Value SetConcept Code Concept Name

Code System Name Code System Version

89628003 Acute suppurative cholecystitis (disorder) SNOMED-CT 20100731

86279000Acute suppurative otitis media with spontaneous rupture of ear drum (disorder SNOMED-CT 20100731

14948001

Acute suppurative otitis media without spontaneous rupture of ear drum (disorder) SNOMED-CT 20100731

8733006 Acute suppurative peritonitis (disorder) SNOMED-CT 20100731

194201001 Acute swimmer's ear (disorder) SNOMED-CT 20100731

279035001 Acute thoracic back pain (finding) SNOMED-CT 20100731

190293001 Acute thyroiditis (disorder) SNOMED-CT 20100731

17741008 Acute tonsillitis (disorder) SNOMED-CT 20100731

26650005 Acute tracheitis (disorder) SNOMED-CT 20100731

OID 2.16.840.1.113883.3.88.12.3221.7.4

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DATA MAPPING

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Document & Section MappingPMD Clinical Template C-CDA H&P Document

A. Chief Complaint Chief Complaint SectionB. History of Present Illness HPI SectionC. Past Medical History History of Past Illness SectionD. Social History Social History SectionE. Review of Systems (ROS) Review of Systems SectionF. Physical Exam Physical Exam SectionG. Patient Assessment Assessment SectionH. Plan Plan of Care Section

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Entry Level Mapping

Clinical Data Element Potential Target Coding

Past Medical History Diagnoses or Problems

SNOMED codes in Problem Value SetICD Code Sets

Functional Assessments International Classification of Functionality

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SWG Artifacts

Data Set Requirements

Data Model

Harmonization with existing C-CDA Document Template and other standards

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Sub Workgroup PMD Structured Data

PMD Phase 1Implementation Guide

Use Case #1: PMD Phase 1PMD Phase 1Pilots (TBD)

Pre-DiscoveryWorkgroup

Charter/Scope

Kick-Off

Mar ‘13 May ‘ 13 July ‘13Feb ‘13 Apr ‘13 Jun ‘13 Aug ‘13

Standards/Data Model/Harmonization

Sub Workgroup PMD Data Capture Template

Sub Workgroup PMD Decision Support

PMD Phase 2Implementation

Guide Use Case #1: PMD Phase 2 Standards/Data

Model/HarmonizationPMD Phase 2 (TBD)

PMD Phase 1

eDoC Timeline

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ChallengesCoordinating work with other S&I Framework Initiatives (HeD and SDC)

Coordinating document types in EMR

Issues of coordination with HL7 regarding gaps in C-CDA or additional templates that must be part of C-CDA

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Community Involvement• Assist with elaboration of use case and variations

• Identification of data elements

• Identification and mapping to standards

• HL7 CDA expertise

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Sub-Work Group Meeting Times

Wednesdays – 2-3 PM Eastern following the esMD Author of Record

Fridays – 2-3 PM Eastern

Next Meeting – Wednesday, March 13. 2-3 PM Eastern

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