1. electronic submission of Medical Documentation (esMD) Determination of Coverage (eDoC) Workgroup Kick-Off of Structured Data Sub-Workgroup March 1, 2013

2. 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 2

3. Agenda Purpose/GoalsProposed ProcessTimeline and SummaryChallengesCommunity ParticipationQuestions 3

4. 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 4

5. 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 5

6. BUSINESS PROCESSES 6

7. eDoC General Workflow Payer Patient LCMP Specialist / Service Provider Physician Templates and Rules 7

8. Visits Physician/ Practitioner Beneficiary Ordering Physician/Practitioner Supplier 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 8

9. Licensed/Certified Medical Professional (LCMP) (PT/OT) Role in Face-to-Face Process Beneficiary Ordering Physician/Practitioner LCMP 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 9

10. EXISTING DATA CAPTURE ARTIFACTS AND DATA ELEMENTS 10

11. CMS PMD Clinical Template 11

12. 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. 12

13. 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 13

14. 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 14

15. C-CDA – History and Physical Allergies 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) 15

16. Sample C-CDA Section History 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). 16

17. 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). … 17

18. ValueSet Problem Value Set Concept CodeConcept Name Code System NameCode System Version 89628003Acute suppurative cholecystitis (disorder)SNOMED-CT20100731 86279000 Acute suppurative otitis media with spontaneous rupture of ear drum (disorderSNOMED-CT20100731 14948001 Acute suppurative otitis media without spontaneous rupture of ear drum (disorder)SNOMED-CT20100731 8733006Acute suppurative peritonitis (disorder)SNOMED-CT20100731 194201001Acute swimmer's ear (disorder)SNOMED-CT20100731 279035001Acute thoracic back pain (finding)SNOMED-CT20100731 190293001Acute thyroiditis (disorder)SNOMED-CT20100731 17741008Acute tonsillitis (disorder)SNOMED-CT20100731 26650005Acute tracheitis (disorder)SNOMED-CT20100731 OID 2.16.840.1.113883.3.88.12.3221.7.4 18

19. DATA MAPPING 19

20. Document & Section Mapping PMD Clinical TemplateC-CDA H&P Document A. Chief ComplaintChief Complaint Section B. History of Present IllnessHPI Section C. Past Medical HistoryHistory of Past Illness Section D. Social HistorySocial History Section E. Review of Systems (ROS)Review of Systems Section F. Physical ExamPhysical Exam Section G. Patient AssessmentAssessment Section H. PlanPlan of Care Section 20

21. Entry Level Mapping Clinical Data ElementPotential Target Coding Past Medical History Diagnoses or Problems SNOMED codes in Problem Value Set ICD Code Sets Functional AssessmentsInternational Classification of Functionality 21

22. SWG Artifacts Data Set Requirements Data Model Harmonization with existing C-CDA Document Template and other standards 22

23. 23 Sub Workgroup PMD Structured Data PMD Phase 1 Implementation Guide PMD Phase 1 Implementation Guide Use Case #1: PMD Phase 1 PMD Phase 1 Pilots (TBD) PMD Phase 1 Pilots (TBD) Pre-Discovery Workgroup Charter/Scope Kick-Off Mar ‘13May ‘ 13 July ‘13 Feb ‘13Apr ‘13 Jun ‘13Aug ‘13 Standards/Data Model/Harmonization Sub Workgroup PMD Data Capture Template Sub Workgroup PMD Decision Support PMD Phase 2 Implementation Guide PMD Phase 2 Implementation Guide Use Case #1: PMD Phase 2 Standards/Data Model/Harmonization PMD Phase 2 (TBD) PMD Phase 1 eDoC Timeline 23

24. Challenges Coordinating 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 24

25. Community Involvement Assist with elaboration of use case and variations Identification of data elements Identification and mapping to standards HL7 CDA expertise 25

26. 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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