HCCIntelligence™ Webinar: Value-Based Care: New Revenue Opportunities for Home-Based Care Practices-Advanced Illness & Frailty Exclusions Guide

Advanced Illness & Frailty Exclusions Guide

Pdf Summary

The "Advanced Illness & Frailty Exclusions Guide" is a resource created by the National Committee for Quality Insurance (NCQA) to assist clinicians in managing Healthcare Effectiveness Data and Information Set (HEDIS) clinical quality and performance measures. The guide acknowledges that certain health measures may not be relevant or clinically appropriate for older adults with serious illnesses, such as controlling high blood pressure. It provides a pathway for clinicians to exclude these patients from specific HEDIS measures if they have advanced illness and frailty codes reported within the same performance year. <br /><br />The document highlights that:<br /><br />1. Reporting requirements and formats may vary among health plans, so clinicians should work directly with their contracted payers, such as Medicare Advantage health plans, to understand their specific expectations.<br />2. Frailty can be demonstrated and reported using Healthcare Common Procedure Coding System (HCPCS) codes for Durable Medical Equipment (DME) and home health utilization. This includes equipment like canes, walkers, wheelchairs, commodes, hospital beds, oxygen, ventilators, and respiratory assist devices such as BiPAP and CPCP. <br />3. Home health HCPCS codes cover services from home health and hospice nurses as well as private duty home personal care services.<br /><br />Clinicians are advised to document the use of DME and home health services in their progress notes. Practices should consider developing processes for coders or staff to review patient charts and submit the appropriate HCPCS codes to ensure proper exclusions.<br /><br />The guide stresses that:<br />- NCQA allows HEDIS measures to exclude patients with advanced illness and frailty due to potential lack of benefit and the possibility of harm from unnecessary tests or treatments. <br /><br />Overall, the guide serves to help clinicians navigate exclusion opportunities for certain patient populations to improve clinical care quality and health plan performance measures without causing unnecessary patient burden.

Keywords

Advanced Illness

Frailty Exclusions

NCQA

HEDIS

Clinical Quality

Performance Measures

HCPCS Codes

Durable Medical Equipment

Home Health Services

Medicare Advantage