MRA Member Summary, Open Conditions & Clinical Inference Best Practices & Next Steps

Member Summary Member Summary Clinical inference section (CIS) The purpose of the CIS in the Humana Member Summary is to identify instances when a patient may have a certain chronic condition, based on clinical analysis of his or her medical, drug and lab claims. About 20 percent of Humana-covered patients have conditions populated in this section, and up to three inferences of data are updated daily. Member Summary A standardized, 365-day snapshot of a patient’s medical history Available for all Humana-covered patients who agree to allow Humana to share their protected health information (PHI) with health care providers Designed to integrate into the practice’s workflow to help identify additional actionable opportunities for improving clinical outcomes Prospective programs are intended to support a face-to-face encounter with the patient and help to facilitate complete and accurate documentation of the patient’s medical conditions. One of the tools available for physician use is the Member Summary. The Humana Member Summary gives a standardized, 365-day snapshot of a patient’s medical history. It is no more than three pages long and is designed to help physicians/health care providers identify additional actionable opportunities for improving clinical outcomes at the point of care. It integrates easily into a physician’s/health care provider’s practice workflow and electronic medical records. The purpose of the clinical inference section is to identify instances when a patient may have a certain chronic condition, based on clinical analysis of his or her medical, drug and lab claims. The patient may already be treated for the condition, but it may not be completely documented in the medical record and corresponding claim.

Member Summary example When to use: Member Summary can be used to identify opportunities to improve clinical outcomes and assist in clinical discussions. The summary also can be used for prospective chart preparation. Tool provides easy access to: Patient demographic data Patient quality Patient admission/ER visits Clinical inference Health condition history Prescription history Lab results The Member Summary can be used to identify opportunities to improve clinical outcomes and assist in enabling discussions with the patient at the point of service, as well as for prospective chart preparation. Information included on the Member Summary is for Humana Medicare- or commercial-covered patients. The information will appear in the following sections of the Member Summary: Patient demographic data Patient quality Patient admission/ER visits Clinical inference section Health condition history Prescription history Lab results The tool provides easy access to, among others: Care alerts Healthcare Effectiveness Data and Information Set (HEDIS®) gaps Patient prescriptions Past diagnoses

CaDET: Prospective review The coding and documentation education and training (CaDET) program is designed to assist physicians in documenting accurately and coding to the highest level of specificity to capture a patient’s true health status at the time of care. Documentation assistance (Chart preparation) 1 Humana educates appropriate office staff on how to prepare the chart before the patient’s arrival. 2 This preparation allows the physician to have targeted discussions with patients at the time of care about conditions that have been documented previously or are clinically inferred. The purpose of the CaDET program is to help physicians document accurately and code to the highest level of specificity to capture a patient’s true health status at the time of care. This is best accomplished by adopting an office work flow that includes two medical reviews: prospective and concurrent. During the training phase of the CaDET program, a Humana educator will help your physicians, coders and office staff to incorporate both reviews into your practice. The first step of the program is prospective review. During this review, the office staff and/or coder review the patient’s medical history prior to a patient’s scheduled appointment to identify and notate in a prospective analysis tool potentially undocumented conditions or diagnoses. We often call this step “chart preparation”. The prospective analysis tool is then attached to the patient’s chart to be reviewed by the treating physician during the patient’s visit. 3 The preparation and discussion will result in improved documentation of the patient’s accurate and complete health status.

CaDET: Concurrent review Coding best practice 1 Once documentation is received from the physician, the Humana educator and appropriate office staff will review the documentation and code accurately. 2 Questions pertaining to the documentation result in a physician query. This process allows the appropriate office staff to message opportunities for documentation improvement directly to the physician. Open lines of communication between physicians and coders are vital to accurately documenting patients’ health conditions. Physician queries help ensure coders are able to appropriately apply the correct coding standards. The second step is the concurrent review. During this review, the practice coder/office staff reviews progress notes from the patient’s visit prior to claims submission to help ensure the physician’s documentation is complete and that the codes submitted to the health plan are accurate. If the office staff/coder has questions about the physician’s document, he or she can query the physician for additional information. This process helps ensure accurate coding that is appropriately supported by the medical record. During the training phase of the CaDET program, the Humana educator instructs the practice coder and/or office staff on best practices for both the prospective and concurrent review. Once the CaDET training is complete, the Humana educator will continue to help ensure success by checking in with the practice on-site or virtually on a quarterly basis reviewing a small retrospective sample set (10-30 members) and up to 10 concurrent reviews for members scheduled to be seen during the visit. 3 The review and query process helps ensure complete and accurate diagnosis code submission on the claim.

Coding Education Webinars Coding education opportunities as well as CEUs for coders & billers CME education opportunities for physicians