Workgroup Charter Review of Electronic Submission and Determination of Coverage (eDoC)

1. electronic submission of Medical Documentation (esMD)electronic Determination of Coverage (eDoC) WorkgroupCharter Review January 30, 2013

2. Welcome and Introductions Melanie Combs-Dyer, RN Deputy Director,CMS / OFM / Provider Compliance Group Dan Kalwa Health Insurance Specialist,CMS / OFM / Provider Compliance Group Michael Handrigan, MD Medical OfficerCMS / OFM / Provider Compliance Group Robert Dieterle, Initiative Coordinator Viet Nguyen, MD Chief Medical Information Officer Systems Made Simple, Inc. Mark D Pilley, MD AAFP, AADEP, ABQAURP Medical Director StrategicHealthSolutions, LLC 2

3. Agenda 3

4. Electronic Determination of Coverage (eDoC) 4

5. eDoC General Workflow Patient LCMP Physician Specialist / Service Provider Templates and Rules Payer 5

6. Scope Out of Scope Specific provider service implementations EHR implementations Provision of Information exchange services (e.g. HISPs for Direct) • In Scope – Phase 1 • Structured and unstructured data requirements • Exchange standards • Digital signature requirements • In Scope – Phase 2 • Templates for Structured Data Capture (SDC) • Decision Support (rules, data capture, order sentences and behaviors) (HeD)

7. eDoC PMD Workflow Patient Signed Document 3 11 1 LCMP Physician DME Supplier 2 5 6 10c 4 8 7 9a 10a 10b 9b Templates and Rules Payer Payer 7

8. eDoC Workgroup Structure 8

9. Structured Information for PMD • Based on clinical template developed by CMS • Available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Downloads/Suggested-PMD-Electronic-Clinical-Template-v98-posted-11-02-12.pdf • Supports • Data collection by providers during face-to-face evaluation • Reporting of clinical information for coverage determination • Clinical decision support and automated determination of coverage 9

10. Components of PMD Clinical Template • Chief Complaint • History of Present Illness • Past Medical History • Review of Systems • Physical Exam • Patient Assessment and Plan • Physician Information and 7 Element Order • Components focused on data to support a PMD order and coverage 10

11. Evaluation Process for PMD Clinical Template • Examination of individual clinical elements for each section of the template • Determine if a clinical element is codifiable (e.g. Diagnosis), requires a narrative (e.g. History of Present Illness), or is mixed (e.g. Review of Systems) • Compare coded elements to existing standard coding systems (e.g. SNOMED-CT, ICD) and CDA components • Develop Templated CDA based on consensus and best practices 11

12. eDoC Workgroup Structure 12

13. Structured Data Capture (SDC)

14. SDC Standards

15. eDoC Workgroup Structure 15

16. Clinical Decision Support

17. Clinical Decision Support

18. eDoC Timeline July ‘13 Mar ‘13 May ‘ 13 Aug ‘13 Jun ‘13 Feb ‘13 Apr ‘13 Pre-Discovery Workgroup Charter/Scope Kick-Off PMD Phase 1 Pilots (TBD) PMD Phase 1 Implementation Guide Use Case #1: PMD Phase 1 Standards/Data Model/Harmonization PMD Phase 1 Sub Workgroup PMD Structured Data PMD Phase 2 Implementation Guide Use Case #1: PMD Phase 2 Standards/Data Model/Harmonization PMD Phase 2 (TBD) Sub Workgroup PMD Data Capture Template Sub Workgroup PMD Decision Support 18 18

19. Summary eDoC workgroup identifies Best Practice for: • Payer interaction with providers for determination of coverage • Developing, delivering and using structured documentation templates to support coverage determination • Developing and instantiating decision support rules to facilitate provider decision making in light of payer standards • Addressing Author of Record requirements • Secure electronic communication between payers, provider, suppliers and beneficiaries • Creating implementation guides for payers and providers (usually via HIT vendors) for all required eDoC processes and transactions 19