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Advanced Illness & Frailty Exclusions Guide
Advanced Illness & Frailty Exclusions Guide
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Pdf Summary
The Advanced Illness & Frailty Exclusions Guide is designed to assist clinicians in reporting advanced illness and frailty diagnoses, which can exclude patients from specific Healthcare Effectiveness Data and Information Set (HEDIS) measures. Governed by the National Committee for Quality Insurance (NCQA), these measures are important for health plan star ratings but may not always be relevant or clinically appropriate for older adults with serious illnesses.<br /><br />Advanced illness and frailty exclusions can help tailor healthcare to be more beneficial for these patients by avoiding unnecessary tests and treatments that could be burdensome or harmful. Clinicians should ensure proper documentation of advanced illness and frailty within their patients' records for potential exclusion from HEDIS measures such as controlling high blood pressure.<br /><br />Frailty can be demonstrated using Healthcare Common Procedure Coding System (HCPCS) codes for Durable Medical Equipment (DME) usage and home health services. Examples of DME include canes, walkers, wheelchairs, commodes, hospital beds, oxygen, ventilators, and respiratory assist devices like BiPAP or CPCP. Home health HCPCS codes cover services provided by home health and hospice nurses, as well as personal care services.<br /><br />Clinicians are advised to document the use of DME and home health services in their progress notes. Practices might also implement processes for coders or staff to review charts and submit the appropriate HCPCS codes for exclusion purposes. It's imperative for practices to understand the specific reporting requirements and formats of their contracted health plans, such as Medicare Advantage, as these can vary.<br /><br />Overall, this guide stresses the importance of recognizing the unique healthcare needs of older adults with advanced illnesses and provides a structured approach for clinicians to exclude such patients from certain HEDIS measures, thereby optimizing their care.
Keywords
Advanced Illness
Frailty Exclusions
Clinicians
HEDIS Measures
NCQA
Healthcare Effectiveness
Durable Medical Equipment
Home Health Services
HCPCS Codes
Medicare Advantage
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