VERA 2013 Patient Classification Handbook - Veterans Affairs
VERA 2013 Patient Classification Handbook This document is published byAllocation Resource Center,a division of the VHA CFO.First EditionTable of Contents TOC \o "1-1" \h \z \t "Heading 2,2,Heading 3,3,Section Breaks,1" Overview PAGEREF _Toc336422690 \h 4Patient Classification Data in the VERA Model PAGEREF _Toc336422691 \h 4Patient Eligibility for VERA Funding Determined by Enrollment Priority Group PAGEREF _Toc336422692 \h 4VERA Payment for High Cost Patients PAGEREF _Toc336422693 \h 5Patient Classification Changes for VERA 2013 PAGEREF _Toc336422694 \h 6Price Groups in the VERA Model PAGEREF _Toc336422695 \h 6Patient Classification Process PAGEREF _Toc336422696 \h 8Telephone Encounters PAGEREF _Toc336422697 \h 8Data Validation PAGEREF _Toc336422698 \h 8Overview of Patient Classification PAGEREF _Toc336422699 \h 9Patient Classes are Hierarchical PAGEREF _Toc336422700 \h 9Basic Vested Classification Criteria PAGEREF _Toc336422701 \h 10Basic Vested Inpatient and Outpatient Workload are Assessed Separately PAGEREF _Toc336422702 \h 10Classification Process Differs for Inpatient and Outpatient Care PAGEREF _Toc336422703 \h 11Classification Timeframes PAGEREF _Toc336422704 \h 13Historical Changes to the VERA Patient Classification System PAGEREF _Toc336422705 \h 14Patient Classification Changes for VERA 2013 PAGEREF _Toc336422706 \h 14Patient Classification Changes for VERA 2012 PAGEREF _Toc336422707 \h 15The 4 Basic Non-Reliant Classes PAGEREF _Toc336422708 \h 20Compensation and Pension (C&P) Exams PAGEREF _Toc336422709 \h 21Employee/Collaterals PAGEREF _Toc336422710 \h 22Non-Vested Patient Class PAGEREF _Toc336422711 \h 23VERA 2013 Vesting CPT Codes PAGEREF _Toc336422712 \h 24Pharmacy PAGEREF _Toc336422713 \h 25The 29 Basic Vested Care Group Classes PAGEREF _Toc336422714 \h 26Acute Mental Disease PAGEREF _Toc336422715 \h 27Acute Myocardial Infarction PAGEREF _Toc336422716 \h 28Addictive Disorders PAGEREF _Toc336422717 \h 29Cardiovascular Disease PAGEREF _Toc336422718 \h 30Care Coordination Home Telehealth – Chronic Care Management PAGEREF _Toc336422719 \h 31Central Nervous System PAGEREF _Toc336422720 \h 32Ear, Nose, and Throat PAGEREF _Toc336422721 \h 33Endocrine, Nutritional, Metabolic Disorders PAGEREF _Toc336422722 \h 34Epilepsy PAGEREF _Toc336422723 \h 35Gastroenterology Disorder PAGEREF _Toc336422724 \h 36Hepatitis C without Anti-Viral Therapy PAGEREF _Toc336422725 \h 37High Cost Conditions PAGEREF _Toc336422726 \h 38High Cost Pneumonia PAGEREF _Toc336422727 \h 39History of Transplant PAGEREF _Toc336422728 \h 40HIV+ without ARV Therapy PAGEREF _Toc336422729 \h 41Homeless Multiple Medical PAGEREF _Toc336422730 \h 43Legally Blind PAGEREF _Toc336422731 \h 44Medical + Psych or Substance Abuse PAGEREF _Toc336422732 \h 45Metastatic Cancer PAGEREF _Toc336422733 \h 46Multiple Medical PAGEREF _Toc336422734 \h 47Multiple Sclerosis PAGEREF _Toc336422735 \h 48Multiple Sclerosis with Pharmaceuticals PAGEREF _Toc336422736 \h 49Musculoskeletal Disorders PAGEREF _Toc336422737 \h 51Oncology PAGEREF _Toc336422738 \h 52Other Acute Diseases PAGEREF _Toc336422739 \h 53Psych+Substance Abuse PAGEREF _Toc336422740 \h 54PTSD – Acute PAGEREF _Toc336422741 \h 55Pulmonary Disease PAGEREF _Toc336422742 \h 56Respiratory Failure PAGEREF _Toc336422743 \h 57The 27 Complex Care Group Patient Classes PAGEREF _Toc336422744 \h 58AIDS or HIV+ with ARV Therapy PAGEREF _Toc336422745 \h 59Blind Rehabilitation Service PAGEREF _Toc336422746 \h 61Care Coordination Home Telehealth – Non-Institutional Care PAGEREF _Toc336422747 \h 62Community Nursing Home PAGEREF _Toc336422748 \h 63End Stage Renal Disease (ESRD) PAGEREF _Toc336422749 \h 64Hepatitis C with Anti-Viral Therapy PAGEREF _Toc336422750 \h 65Home-Based Primary Care (HBPC) PAGEREF _Toc336422751 \h 66Homeless Chronic Mentally Ill (CMI) PAGEREF _Toc336422752 \h 68Legacy LTC/Intermediate PAGEREF _Toc336422753 \h 71Long Stay Community Living Center (CLC) PAGEREF _Toc336422754 \h 72Mental Health Intensive Case Management (MHICM) PAGEREF _Toc336422755 \h 73Other Psychosis PAGEREF _Toc336422756 \h 75Polytrauma PAGEREF _Toc336422757 \h 77PTSD – Chronic PAGEREF _Toc336422758 \h 78Residential Rehabilitation PAGEREF _Toc336422759 \h 80Schizophrenia and Dementia PAGEREF _Toc336422760 \h 81VERA 2013 DSS Clinic Stops for the CMI Retention Criteria PAGEREF _Toc336422761 \h 83Short Stay Community Living Center (CLC) PAGEREF _Toc336422762 \h 85Skilled Nursing and Rehabilitation (CLC) PAGEREF _Toc336422763 \h 86SCI Para – New Injury or Institutionalized PAGEREF _Toc336422764 \h 88SCI Para – Old Injury PAGEREF _Toc336422765 \h 89SCI Quad – New Injury or Institutionalized PAGEREF _Toc336422766 \h 90SCI Quad – Old Injury PAGEREF _Toc336422767 \h 91Stroke PAGEREF _Toc336422768 \h 92Substance Abuse PAGEREF _Toc336422769 \h 94Transplant PAGEREF _Toc336422770 \h 95Traumatic Brain Injury PAGEREF _Toc336422771 \h 96Ventilator Dependent PAGEREF _Toc336422772 \h 98VERA 2013Patient Classification System Overview The Veterans Equitable Resource Allocation (VERA) Model is used to allocate financial resources to the 21 Veterans Integrated Service Networks (VISNs) in VHA. Implemented for the first time in mid-1997, the VERA Model has been subject to several internal and external evaluations, to ensure its integrity as a resource allocation methodology. As such, the VERA Model has been honed over the years to ensure that it complies with VHA’s mission and current clinical practice patterns. While the VERA Model is designed to allocate funds at the VISN level, the underlying data components of the VERA Model rely on comprehensive data systems that track and analyze the many management information systems used in health care administration. One of the primary components of the VERA Model is the Patient Classification (PC) System, which is maintained by the Allocation Resource Center (ARC); a unit within the VHA Office of Finance. The PC system uses patient care data obtained from VHA’s national data repositories to categorize patients into mutually exclusive patient classes. For the VERA 2013 Model, there are 60 mutually exclusive patient classes, including 1 new class since the VERA 2012 Model and modifications to a few existing classes. The classes are aggregated into 10 VERA Price Groups and new prices are computed using the current year appropriation. The VERA Price Groups are used to fund patient care in the VERA Model. In recent VERA Models, approximately 90% of the funds allocated by the model are directly attributed to patient care practices. The VERA 2013 Patient Classification System is relatively the same as the prior year Model with the exception of one new class and revisions to the classification criteria for three existing patient classes. All changes made in prior years are documented in the Historical Changes paragraph of this document. Each year, the VA provides a wide array of healthcare services to approximately 6 million veterans nationwide. The Patient Classification System provides the integral patient-specific data for resource allocation and management reporting. In general, the classification system is a multifaceted system that categorizes all VA patients into specific classes representing their clinical conditions and resource needs. The data generated by the patient classification system is used in the VERA Model and many other VA reports that assist VA managers in their day-to-day operations. In addition to the VERA Model, patient classification data is used in reports and studies to provide valuable information about the VHA’s patient care workload. It should be noted that in addition to Patient Classification, the ARC is responsible for assigning costs to patients following the classification process. The patient costing process is not addressed in this document. Patient Classification Data in the VERA Model To ensure equitable funding of health care across the country, the VA uses the VERA Model to distribute medical care funds to the 21 Network offices that are geographically dispersed across the nation. In brief, the VERA Model is a capitated-funding model, designed to apportion medical care funds in accordance with Network-level patient healthcare practices. The Network-level healthcare practices are identified by the patient classification system, which categorizes all patients receiving treatment provided or paid for by the VHA into one of 60 patient classes during a federal fiscal year. These patient classes are aggregated into the VERA price groups that ultimately distribute the patient care budget to VISNs within the VERA Model. Patient Eligibility for VERA Funding Determined by Enrollment Priority GroupBeginning with the VERA 2004 model, all treated veterans with the exception of veterans on Sharing Agreements or TRICARE are VERA-funded. In models prior to 2004, eligibility for VERA funding was based on a patient’s Means Test; high income veterans and non-veterans in Basic Care classes were not eligible for VERA funding. Since the VERA 2004 model, eligibility for VERA funding is determined by the patient’s enrollment status, maintained by the VHA Health Eligibility Center (HEC). The VHA Office of Policy and Planning, in conjunction with the HEC and the VHA Support Services Center, provides the ARC with monthly reports that categorize treated veterans into specific Enrollment Priority Groups based on factors such as service-connected conditions, income and/or net worth etc. In addition to veterans, the VERA Model funds non-veterans that present for Compensation and Pension exams as well as non-veterans that qualify for a Complex Care patient class at the same rate as patients in Enrollment Priority Groups 7&8. Complex Care patients on Sharing Agreements or TRICARE are not VERA-funded; the exception to this is for the patient in the new Polytrauma class. All Polytrauma patients, including those on TRICARE and Sharing agreements are VERA-funded. The precise VERA funding is contingent upon several factors, including the patient’s HEC Enrollment Priority Group and VERA Price Group, as determined by the patient’s VERA class. Note that the VERA Model funds enrolled patients that received treatment in the VHA healthcare system but does not fund patients that are enrolled but did not receive VHA services. The priority group is obtained from the Enrollment database maintained by the HEC. Since the VERA 2004 model, two sets of VERA prices have been computed to reflect the differences in the resource needs of veterans in Priority Groups 1-6 and Priority Groups 7 & 8. Analysis revealed that patients in Enrollment Priority Groups 7&8 generally do not use the VHA at the same level as patients in Enrollment Priority Groups 1-6. Therefore, VERA prices for Priority Group 7 & 8 are somewhat reduced from the prices computed for Enrollment Priority Groups 1-6. In addition to the two sets of VERA prices, there is a single price group for patients with a minimum of 90 bed days of care (BDOC) in a VHA Community Living Center (CLC). This price group is identified as 10A Long Stay (LS) CLC and includes a single price for patients in Enrollment Priority Groups 1-8. VERA Payment for High Cost PatientsIn addition to a Price per patient for VERA-eligible patients, the VERA Model includes a High Cost payment for certain VERA-funded patients whose annual costs exceed an established threshold for a given year. VISNs with VERA-funded patients that exceed the threshold of costs for a given year receive dollar for dollar the amount in excess of the stated threshold for the year to compensate VISNs for extremely expensive patients. In prior VERA Models, the high cost threshold has been determined as the one percent (1%) most costly patients in Enrollment Priority Groups 1-6. Furthermore, beginning with the VERA 2011 Model, patients in the Long Stay CLC Price Group (10A) became eligible for a high cost payment as analysis revealed that a payment was necessary due to excessive costs associated with lengthy stays in VHA’s Community Living Centers (CLC’s). This policy ensures equitable funding for this costly population. The chart below illustrates the thresholds for the respective VERA Models. The FY Date column indicates the most recent year of data used in the respective VERA Model. This FY is reviewed for patients that exceed the high cost threshold. Model YearFY DateStandard ThresholdLong Stay ThresholdVERA 20132011$108,000$218,000VERA 20122010$108,000$214,000VERA 20112009$107,000S222,000 Patient Classification Changes for VERA 2013 The VERA 2013 Patient Classification system contains a new class and revisions to a series of other classes. In addition, the order of some classes within the Patient Classification hierarchy changed, particularly within Price Group 10. Including the new class for this year, there are 60 Patient classes in the classification hierarchy. The newly added class is titled Epilepsy in Price Group 4, capturing a costly cohort of patients that have received care for Epilepsy. Criteria for all classes in the Significant Diagnosis Price Group (6) was modified to ensure that this group captured the most costly group of patients that have presented for inpatient care for their conditions (i.e. Acute MI, Metastatic Cancer, Respiratory Failure). An overview of the changes is explained in the Historical Changes section and on each Patient Class page within the handbook. Price Groups in the VERA ModelSince the VERA 2004 model, the VERA Model has contained two sets of VERA 10 prices to more accurately account for resource differences in patients in Enrollment Priority Groups 1-6 versus 7 & 8 and funded non-veterans. Each VERA price group contains between one and eight patient classes and was formed based on clinical and cost factors. The VERA Patient Classification chart displayed on the next page, illustrates the correlation between the VERA 2013 Price groups and the 60 patient classes. The actual VERA Prices are computed each year and are contingent upon the VHA budget and the number of patients within each price group. A tutorial on the ARC website explains the methodology and provides a detailed process for computing the prices. In brief, the formula for computing VERA Model prices is based on historical costs as a base, modified to include budget increases. As indicated above, two sets of VERA 10 Prices were computed: the first set for patients treated in Enrollment Priority Groups 1 through 6, and a second set of VERA 10 Prices for patients in priority groups 7 and 8. Analysis revealed that creating a second set of VERA 10 prices for patients in Priority Groups 7 & 8 is appropriate because the costs of caring for the majority of these patients is less than the cost for patients in Priority groups 1 – 6. Beginning with VERA 2010, a new Price Group identified as 10A, was established to fund patients in the Long Stay CLC patient class. The Long Stay CLC Price Group includes patients with at least 90 bed days of care (BDOC) in VHA’s Community Living Centers (CLC) resulting in very high annual costs. To ensure adequate funding for this population, a single Long Stay CLC price is set for this population. The expanded number of VERA price groups vastly improves the correlation between patient costs and patient care funding. In brief, the formula for computing the VERA prices begins with the historical costs of each price group, and is modified by budget increases for the given year. For more information on the process for computing the VERA prices, consult the ARC tutorial, Computing VERA Prices for Patient Care at VERA 2013 Patient Classification HierarchyBasic Non-ReliantPrice Group List (#)VERA Patient ClassNon-reliant Care (1)1. Employee/Collaterals3. Compensation and Pension (C&P) Exam2. Pharmacy4. Non-Vested Patient??BASIC VESTED CAREBasic Medical/Ht, Lung, GI (2)5. Other Acute Diseases9. Central Nervous System6. Ear, Nose and Throat10. Cardiovascular Disease7. Endo Nurt. Metab Disorders11. Gastroenterology8. Musculoskeletal Disorder12. Pulmonary Disease??Mental Health (3)13. Acute Mental Disease14. Addictive Disorders?Oncology/Inf. Dis./L. Blind (4)15. HIV+ w/out Anti Retro-Viral Therapy18. Oncology16. Legally Blind19. Epilepsy 17. Hepatitis C w/out Anti-Viral Therapy?20. Multiple Sclerosis??Multiple Problem (5)21. Medical/Psych+Substance25. Homeless Multiple Medical22. CCHT - Chronic Care Management26. Multiple Medical23. Multiple Sclerosis w/Rx27. History of Transplant24. Psych+Substance Abuse28. PTSD - Acute??Significant Diagnoses (6)29. Acute MI 32. High Cost Pneumonia30. Metastatic Cancer33. High Cost Conditions31. Respiratory Failure?????COMPLEX CARESpecialized Care (7)34. Hepatitis C with Anti-Viral Therapy37. Chronic PTSD35. AIDS or HIV+ w/ ARV Therapy38. CCHT-Non -Institutional Care36. Stroke39. Traumatic Brain Injury & Polytrauma AC??Supportive Care (8)40. Home-Based Primary Care (HBPC)44. Legacy LTC/Intermediate41. Blind Rehabilitation Service45. Skilled Nursing & Rehab (CARF)42. Residential Rehab. ( Domiciliary)46. SCI Para-old Injury43. Community Nursing Home47. SCI Quad-old Injury??Chronic Mental Illness (9)48. Substance Abuse51. Schizophrenia & Dementia49. Homeless-CMI52. Mental Health Inten. Case Mgt (MHICM)50. Other Psychosis???Critically Ill (10)53. Short Stay CLC 57. SCI Para-New Injury/ SCI Instit 54. End Stage Renal Disease 58. SCI Quad-New Injury/ SCI Instit.55. Polytrauma59. Ventilator Dependent56. Transplant.???Long Stay (10A)60. Long Stay CLC?Patient Classification ProcessEach year the Allocation Resource Center (ARC) completes the patient classification process using numerous data sources, the majority of which are obtained from the Corporate Data Center Operations (CDCO) formerly known as the Austin Automation Center (AAC). Patient classification is a national process, meaning that all appropriately documented patient care provided during the fiscal year is considered in the process provided it is transmitted to AAC by the official close of the fiscal year. The official close, also known as the hard close for the fiscal year is October 7. The ARC completes the patient classification process by strategically placing every patient treated in the VHA healthcare system into a single patient class based on the total care received during the course of the fiscal year. While the majority of patient health care is typically provided by the VHA, some patients receive contracted care, also known as non-VA or Fee care, which is paid for by the VA. Most contracted care is considered in the classification process, provided it is paid for by the VA and properly documented in the VHA’s databases. For some of the Complex Care classes, a non-VA Patient Treatment File must be completed as well. The data sources used in the patient classification process include:Patient Treatment Files (PTF);Census files, which are completed each quarter;National Patient Care Database (NPCD) encounter and visit files including the Inpatient Encounter (IE) file in isolated classes. Note that the classification criteria will specify if IE data is included in the patient class; Fee Payment Files (contract hospital files and ambulatory care fee files). In addition, as of fiscal year 2010, payments made through the VA Austin Financial Services Center (FSC) for the contract dialysis National pilot project;Clinical Case Registry (CCR);Resident Assessment Instruments/Resource Utilization Groups (RUG) III scores; Pharmacy Benefits Management (PBM) database; CCHT data maintained by the VSSC and Electronic webmail to the ARC for home dialysis patients. Telephone EncountersTelephone encounters are identified by specific DSS Clinic Stops and the workload is maintained in the National Patient Care Database (NPCD). Workload associated with telephone encounters is used in the classification process for Basic Care patients. It should be noted that while most Complex Care classes require specific levels of workload in a given fiscal year, certain Complex Care classes include class protection if the patient receives care in a subsequent year. For example, the SCI Old Injury, Stroke and TB/Polytrauma Aftercare classes have multi-year classification protection when patients receive care in a subsequent year. However, class-protected Complex Care patients that only receive telephone care or secure messaging (as documented by secondary DSS clinic stop 719) in a fiscal year will be removed from the VERA Complex Care class and placed in the most appropriate Basic Vested class that correlates to their diagnoses. This process ensures that Complex Care patients that receive exclusively telephone care or secure messaging as their only episodes of care in a fiscal year will not be overfunded in the VERA Model. Note that DSS Clinic Stops designated as telephone encounters are different from telehealth encounters, and that telehealth workload is used in the VERA Model. Data ValidationThe ARC website contains numerous reports to assist field staff in monitoring patient workload. The Data Validation Tutorial available on the ARC website offers several suggested strategies for monitoring and validating workload. ARC patient workload and cost reports are published each month throughout the course of the fiscal year. In addition, patient specific data is available to staff that have been granted the authority to view patient-specific information. In addition to ARC reports, field offices should monitor certain reports to ensure that patient records are successfully transmitted from their station to the Austin Corporate Data Center Operations (CDCO) as part of an ongoing data validation process. Some of these reports include: PTF Error report 419 Report (which is an electronic report); Error Analysis Listing (EAL);PTF Census 250 Report;VistA option, Transmission History for Patient;NPCD transmission error listing, specifically the Incomplete Encounter Error Report. Overview of Patient ClassificationIn general, the Patient Classification System consists of three distinct clinical care groups: Complex Care, Basic Vested Care and Basic Non-Reliant Care, totaling 60 patient classes. Complex patients tend to be more resource intensive than Basic Vested or Non-reliant patients. Two classes, Pharmaceuticals (only), and the Employee/Collaterals patient class are not VERA-funded when no other care is received during the three proxy fiscal years covered by the VERA Model. Data pertaining to these two patient classes is collected for reporting purposes. The chart below illustrates the relationship between the care groups and the number of patient classes and price groups. Number of Patient Classes Price Groups (number) 27 Complex Care patient classesLong Stay CLC (10A)Critically Ill (10)Chronic Mental Illness (9)Supportive Care (8)Specialized Care (7)29 Basic Vested patient classesSignificant Diagnoses (6)Multiple Problem (5)Oncology/Infectious Disease (4)Mental Health (3)Basic Medical/Heart, Lung, GI (2)1 Compensation & Pension Exam1 Employee/Collateral patient class1 Non-Vested patient class1 Pharmacy (only) patient classBasic Non-reliant (1)60 Total VERA classesPatient Classes are Hierarchical The patient classification schema is hierarchical, meaning that the classes are ordered based on specific classification criteria. In addition, patient classification is a mutually exclusive process, meaning that patients are placed in the one patient class that best describes the total care received during the fiscal year. For example, patients in the Basic Vested patient classes do not meet the criteria for any of the Complex Care patient classes. The precise criteria for each class are developed from the patient’s diagnoses and/or their utilization of healthcare resources. Diagnoses are obtained from the medical records, while utilization criteria takes into account clinical services provided and/or bed days of care (BDOC). Although patients frequently meet the criteria of more than one class, the classification process strategically places each patient into the single highest class s/he qualifies for based on total care received during the fiscal year. (See the VERA 2013 Patient Classification Hierarchy chart.) It should be noted that the ARC uses internal registries to track specialized populations over time. Although these ARC registries are referenced in this document, the actual data is not available to ARC customers. The VERA Patient Classes are constructed to reflect the case mix of patients based on resource intensity. The building blocks of the Patient Classification schema are derived from a nationally recognized system supported by the Centers for Medicare and Medicaid Services (CMS) that strategically maps diagnosis codes to Major Diagnostic Categories (MDCs). In brief, the MDCs correspond to an organ system or are associated with a medical specialty. The classification process works from the highest to the lowest classes, meaning that patient workload is assessed for the Complex Care classes first. The Complex Care classes contain precise criteria (clinical codes, diagnoses and utilization factors) that must be met during a specified timeframe. The precise requirements are documented in each of the Complex Care class criteria in this handbook. Historically, only a small percentage of VHA’s patient population (4% or less) qualifies for a Complex Care class. All other patients are placed in a Basic Care patient class. Basic Vested Classification CriteriaIn general, Basic Vested patients are best described as those patients who use the VA for their primary and acute healthcare needs. A patient is considered Vested when a minimum level of healthcare services has been provided indicating, in general that the patient has received the equivalent of primary care services at least once during a rolling three year timeframe. The precise clinical services include either: -an inpatient admission or observation stay of less than 24 hours, or-outpatient care that in general, equates to a primary care visit by a clinician authorized to administer a primary care visit. A primary care visit is identified by a list of specific Current Procedural Terminology (CPT) codes identified in this manual. These codes must be administered by at least one clinical provider authorized to complete the equivalent of a history and physical. The precise CPT codes and authorized providers are identified in the documentation of the Non-Vested patient class. A patient is required to meet the Vesting criteria once during the current year or the prior two fiscal years. Patients that do not meet the Vesting requirements are placed in the Non-Vested patient class. (See Non-Vested Class for specific class criterion.)Once the Vesting criteria is met, the patient is placed in one of the 29 Basic Vested patient classes that best describes all services received during the given fiscal year or the Comp and Pension patient class if the purpose of the visit was a Compensation and Pension exam. The classification criteria for the Basic Vested patient classes are typically based on a patient’s principal/primary diagnosis, which is documented in the inpatient and/or outpatient databases. In certain instances, coding requirements mandate a specific ordering of diagnosis codes and require that certain codes be listed as secondary. For this reason, the following classes include secondary diagnosis codes as part of the classification criteria: Legal Blindness, High Cost Pneumonia, High Cost Conditions, Homelessness, Metastatic Cancer, Multiple Sclerosis, Respiratory Failure and the dual diagnosis Psych+ Substance Abuse patient classes. Refer to the corresponding page for each of these classes to obtain the precise classification rules. Note that for inpatient classification rules, secondary diagnosis codes must be listed in the 501 section of the PTF as the 701 section is not used in the Patient Classification process. For these particular classes, assessing secondary diagnosis codes ensures accurate identification of these patients. Basic Vested Inpatient and Outpatient Workload are Assessed SeparatelyBeginning with the VERA 2010 Model, the patient classification process assesses inpatient care and services provided in an ambulatory setting (commonly referred to as outpatient care) separately. Inpatient care (which also includes care provided in a bed section designated as an observation treating specialty) is documented in a Patient Treatment File (PTF) and the reason for care is identified as the principal diagnosis code. Outpatient care is documented in the National Patient Care Database (NPCD) and includes a primary diagnosis code as the reason for care. Healthcare Common Procedure Coding System (HCPCS) clinical codes are used to document the clinical services received for a particular diagnosis. It should be noted that the Inpatient Encounter (IE) file tracks HCPCS workload provided in precise DSS Clinic Stops while the patient is receiving care as an inpatient. The IE file workload is used in a limited number of classes, including the ESRD patient class, History of Transplant class and the Chronic Mentally Ill Complex Care classes. Non-VA care that is purchased and paid for in the Fee Payment System is also used in the patient classification process. The classification process assesses all inpatient and outpatient services separately to ensure that all clinical care provided is considered in the patient classification process. In brief, the patient is placed in the highest Basic Vested class the patient qualifies for based on the independent assessment of inpatient care and an independent assessment of outpatient care. In some cases, it is the combination of both inpatient and outpatient care that qualifies a patient for a Multiple Problem patient class, thereby reflecting the fact that the patient is receiving care for more than one major body system. The process of evaluating both inpatient and outpatient care is distinctly different from prior classification systems prior to VERA 2010, which based classification exclusively on inpatient care even when both inpatient and outpatient care was evident. The process to prioritize inpatient care for Basic Care patients was rescinded beginning with the VERA 2010 Model. Presently, a patient’s outpatient care may result in a higher Basic Vested class than an inpatient admission, a situation that was not possible under classification systems prior to VERA 2010. Classification Process Differs for Inpatient and Outpatient Care The patient classification process for inpatient care differs from that for outpatient care. In general, classification of inpatient care relies primarily on the principal diagnosis, whereas outpatient classification is contingent upon the actual level of services provided for each primary outpatient diagnosis code. Otherwise stated, patient classification is based on the predominant services provided to the patient. Determining the predominant services requires assessing the levels of clinical services provide for each primary diagnosis code, and assigning that care to the corresponding Major Diagnostic Category (MDC). The predominant MDC ultimately determines the appropriate patient class. The details for each type of care are identified below.Inpatient Care (including care in Observation Treating Specialties): Inpatient care is documented in Patient Treatment Files (PTFs) that contain the diagnosis codes used in the patient classification process. For the most part, the principal diagnosis code(s) documented in the discharge PTFs (501 screen) and the bed transfer segments are used in the classification process. There are certain classes that rely on secondary diagnosis codes due to coding rules. The individual patient class pages in this handbook identify the precise criteria and qualifying codes for each class. Finally, Census PTFs are data source for patients that reside in the hospital at the close of a fiscal year.Outpatient Care: Unlike inpatient care, outpatient classification is based on the predominant outpatient diagnosis, which is determined by the level of workload associated with each primary diagnosis code. Provided the patient has met the Vesting requirements, patient classification for outpatient care is determined by the highest level of clinical workload associated with the primary diagnosis code. Specifically, outpatient clinical services are documented using Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) II codes that describe the clinical services provided. Each year, the Centers for Medicare and Medicaid Services (CMS) assign a series of weighted values known as the Relative Value Units (RVUs) to each clinical code. Although the RVU system was initially designed to assign reimbursement rates to Medicare services, it has widespread use in the healthcare community. These RVUs are updated each year as part of the Resource-Based Relative Value Scale (RBRVS) annual publication. The RBRVS publication assigns a series of relative values (in the form of numeric units) based on the costs required to provide the services. One of the many values of the RBRVS is a factor known as the “Work” RVU, which is used to describe the physician’s clinical work component of a clinical code. The VERA Patient Classification process uses the sum total of “Work RVUs” for each primary outpatient diagnosis to determine the predominant diagnosis codes in a given fiscal year. In brief, the Work RVUs quantify the clinical workload component of the outpatient clinical services. In some situations, the ARC has imputed values for certain HCPCS II codes that did not have a Work RVU. The list of codes and their ARC-imputed values are identified in Appendix E. (Procedure codes without a diagnosis code are excluded in the process.) When a patient has multiple outpatient encounters with different diagnoses, the predominant diagnosis code is used in the classification process. The predominant diagnosis determines the appropriate MDC that ultimately determines the VERA patient class. Combine Inpatient and Outpatient Care: When a patient receives a combination of both inpatient and outpatient care during the fiscal year, the patient is placed in the highest patient class based on the independent assessment of inpatient care and outpatient care. If the patient has significant care in more than one MDC, the patient may qualify for a patient class within the Multiple Problem Price Group, indicating that the patient is receiving significant care in more than one major body system. Significant care is identified as either an inpatient admission or outpatient care that equates to at least 7 Work RVUs in a MDC. (Note that care is recorded as either inpatient care or outpatient care and therefore data in the Inpatient Encounter (IE) file is not used for this purpose. Patients with significant care in more than one MDC may be assigned to the combination class within the Multiple Problem Price Group that best describes the combination of body systems treated (e.g. Multiple Medical, Medical/Psych + Substance Abuse or the Psych + Substance Abuse patient class). The Basic Vested patient classification assignment is determined when a patient’s principal diagnosis code(s) are correlated (or mapped) to a specific Major Diagnostic Category (MDC) that identifies the precise body system(s) affected. MDCs include a group of similar diagnostic related groups, such as those affecting a given organ system of the body. The MDCs include all principal diagnoses organized into 25 mutually exclusive diagnosis areas that correspond to a single organ system or are associated with a particular medical specialty. MDC 1 to MDC 23 are grouped according to principal diagnoses. MDC 24 (Multiple Significant Trauma) has at least two significant trauma diagnosis codes from different body site categories. MDC 25 identifies HIV conditions. Although there is a group identified as Pre-MDC, unlike the other MDCs, it can be reached from a number of diagnosis/procedure situations, all of which are transplant-related. Transplants are addressed separately in the VERA Patient Classification process. Finally, note that MDC 23 includes ICD-9 V57 Rehabilitation procedures, and that the majority of other diagnosis codes are mapped to other MDCs as indicated in Appendix B. The following is a list of the 25 Major Diagnostic Categories (MDCs):MDCMDC Title1.Diseases and Disorders of the Nervous System2.Diseases and Disorders of the Eye3.Diseases and Disorders of the Ear, Nose, Mouth and Throat4.Diseases and Disorders of the Respiratory System5.Diseases and Disorders of the Circulatory System6.Diseases and Disorders of the Digestive System7.Diseases and Disorders of the Hepatobiliary System and Pancreas8.Diseases and Disorders of the Musculoskeletal System and Connective Tissue9.Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast10.Endocrine, Nutritional and Metabolic Diseases and Disorders11.Diseases and Disorders of the Kidney and Urinary Tract12.Diseases and Disorders of the Male Reproductive System13.Diseases and Disorders of the Female Reproductive System14.Pregnancy, Childbirth and the Puerperium15.Newborns and Other Neonates16.Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders17.Myeloproliferative Diseases and Disorders, and Poorly Differentiated Neoplasms18.Infectious and Parasitic Diseases19.Mental Diseases and Disorders20.Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders21.Injury, Poisonings and Toxic Effects of Drugs22.Burns23.Factors Influencing Health Status and other Contacts with Health Services (Rehabilitation services coded as V57.xx are captured in MDC 23, all other MDC 23 diagnosis codes are re-mapped to other body systems. Appendix B identifies the re-mapping of MDC 23 codes.)24.Multiple Significant Trauma25.Human Immunodeficiency Virus Infections (See Appendices A and B for the relationship between ICD-9 codes and MDCs.) In some situations, an outpatient may have multiple diagnoses that map to more than one MDC. In such cases, the actual health care services provided are used to determine the appropriate patient class. Classification TimeframesPatient Classification is done each month, and ARC website reports indicate that patients can move between classes within the hierarchy during the course of a given year. However, the patient’s official patient class for the fiscal year is based on the cumulative patient record consisting of all appropriately documented patient care spanning the fiscal year timeframe October 1 through September 30. All encounters and hospital stays during the timeframe are assessed in the classification process, including all inpatient and outpatient care. The only exception to the fiscal year timeframe pertains to patient classes that use bed days of care (BDOC) as part of the classification criteria. The process for counting BDOC begins with the patient’s discharge date and extends back to the admission date, even if the admission date occurred in a prior fiscal year. It is important to note that “pass days”, which include “absent bed occupied” (ABO) days, are excluded from the calculation of BDOC. For example, in cases where the admission date occurred in a prior fiscal year, the BDOC are counted from the admission date to the discharge date, and pass days are excluded. This process is used only when a patient’s length of stay spans two fiscal years (i.e. the patient was a census patient on the night of September?30). This process ensures that the BDOC are accurately counted when they are a classification factor, i.e. for Long Term Care patient classes and the Substance Abuse patient class. Furthermore, steps are taken to ensure that BDOC are not doubly counted in subsequent classification years. The precise criteria for each patient class are identified in the subsequent pages. The patient classification process is completed each fiscal year for all patients treated in the VHA system, regardless of whether the patient is VERA-funded. The timeframe associated with the majority of patient classes is annual, meaning that patients must meet the class criteria each year to remain in the patient class. However, certain classes have multi-year timeframes due to the clinical complexities associated with these classes. Throughout the classification chapter, each patient class has a specified timeframe associated with the class. The classification timeframes are defined as follows:Annual: Patient must meet class criteria each fiscal year. Three-year: Patients are maintained in the patient class for the two immediately following classification years provided they present for treatment. The three-year clock resets each time the patient meets the inpatient class requirements. Multi-year: Patients are maintained in the patient class as long as the specified retention criterion is met each successive fiscal year. If the retention criteria are not met, the patient is re-classified according to the new levels of care and/or diagnoses. Permanent: Patients are maintained in a specific class on a permanent basis, meaning that the patient will not be placed in a class that is lower on the classification hierarchy once placed in a permanent class. Permanent classes do not require that the patient be treated in every successive year; however, the patient must receive treatment to be counted as part of the class workload in a given year. Historical Changes to the VERA Patient Classification System Below is an overview of the major changes to the Patient Classification system for VERA Models. The changes are identified by VERA Model year and represent the major changes to classification criteria or the classification process from the prior year. Note that these changes do not necessarily identify actual clinical coding changes or updates that may have occurred each year. Patient Classification Changes for VERA 2013 The VERA 2013 process included a new Patient Class and modifications to a series of other patient classes as indicated below. The new class for VERA 2013 is the Epilepsy class (#19) which identifies patients with a principal inpatient diagnosis code of Epilepsy, ICD-9 345.XX or a primary outpatient diagnosis code. The Epilepsy class will be funded in Price Group 4. The Complex Care class; Skilled Nursing and Rehabilitation (#45) was modified to include a new Rehabilitation diagnostic (dx) patient class to identify patients that have received inpatient care on VHA Commission on Accreditation for Rehabilitation Facilities (CARF) bed sections as well as high levels of rehabilitation service during the year. The CARF is a national accrediting body for facilities providing rehabilitative services. Patients qualify for the Rehabilitation dx class if they have been admitted to VHA Rehabilitative Medical Services (RMS) Treating Specialties (TS) 20 or 82 and have received high levels of rehabilitation services that are documented in the Inpatient Encounter (IE) file or the National Patient Care Database (NPCD). Specifically, in addition to an inpatient admission, patients must receive at least 15 hours of rehabilitative services in the fiscal year, which must be documented in the IE file or the NPCD using qualifying CPT codes. Each encounter form will be assessed for up to one hour of care based on the precise CPT codes that range from 97010 to 97546. Each qualifying code is valued at 15 minutes per code and the encounter is limited to a maximum of 60 minutes per encounter form. Non-VA care is not considered for this patient class. Changes in Classification Criteria The Significant Diagnosis Price Group (6) had changes to all five patient classes. - Respiratory Failure, High Cost Pneumonia, High Cost Conditions patient classes: Inpatient care: This year, the patient classification criterion has been modified to comply with coding rules that allow secondary diagnosis codes when other clinical conditions are evident. The precise diagnosis codes for the classes above can be listed as either primary or secondary diagnosis codes in the PTF 501 segment of the Patient Treatment File (PTF). -Outpatient care: Exclusively outpatient care for corresponding diagnosis codes associated with Respiratory Failure, High Cost Pneumonia, High Cost Conditions and Acute Myocardial Infarction (Acute MI) that are not followed by an admission on the same day will no longer qualify for these classes. A patient receiving outpatient care for the qualifying diagnosis codes will qualify for this class only when a hospital admission occurs on the same calendar date of care. The admission date of a PTF (or a non-VA PTF) must be the same calendar date as the outpatient encounter to qualify for this patient class. For example, the Acute MI patient class requires a principal inpatient ICD-9 diagnosis code of 410.X1. A matching admission date is necessary because the admitting diagnosis would not include the ICD-9 code 410.X1 as principal diagnosis code if the patient was admitted for cardiac surgery. -Metastatic Cancer: The diagnosis codes for metastatic cancer can be either primary or secondary and may occur as either inpatient or outpatient care. If the diagnosis code is outpatient, the patient must have received outpatient workload that equates to a minimum of 3.5 “CMS Work” relative value units (RVUs). In prior classification years, this class required a minimum of 7.0 CMS Work RVUs. All patients that have “class protection status:” Complex Care patients that exclusively received telephone care and/or Secure Messaging in the fiscal year with no other care would be placed in the most appropriate Basic Care class to account for this workload. This includes patients in classes such as SCI Old Injury, TBI/ Polytrauma Aftercare and Stroke; all of which are multi-year classes that afford class protection in subsequent years when care other than a telephone visit or secure messaging occurs. The telephone encounters are documented by specific DSS clinic stops and secure messaging includes encounters that have a secondary DSS clinic stop of 719. This process ensures that VISNs are not over-funded for workload that is exclusively telephone encounters and/or secure messaging as noted above. Basic Care Hepatitis C: All patients with Hepatitis C must be registered in the Clinical Case Registry (CCR), in accordance with the VHA Directive 2011-026. This ensures that the VERA Patient Classification criterion complies with VHA policies. Patient Classification Changes for VERA 2012 The VERA 2012 Patient Classification system contains four changes since the prior model, including a new patient class bringing the total number of patient classes in the Patient Classification hierarchy to 59. The newly added class is titled Polytrauma and captures patients that have received care in a VHA Polytrauma Center. The three remaining changes address modifications to the classification criteria for three Patient Classes. Each of the four class changes are explained below in greater detail. Polytrauma: The Polytrauma (PT) Patient class is funded in the Critically Ill Price Group (#10) and includes a costly cohort of patients that have received inpatient care in a designated VHA Polytrauma unit, which is identified as Treating Specialty 1N. A patient will qualify for the Polytrauma class with an inpatient admission to a VHA Polytrauma unit (at least one bed day of care (BDOC) in a fiscal year followed by confirmation of care by the Polytrauma Program Office. Additionally, unlike other Complex care patient classes, all Polytrauma patients, including patients with an eligibility status of Tricare or Sharing Agreement will be VERA-funded. In the immediate three subsequent fiscal years following a discharge from a Polytrauma unit, a Polytrauma patient will fall no lower than the Traumatic Brain Injury (TBI) /Polytrauma patient class when s/he presents for either inpatient or outpatient care. Blind Rehabilitation: The bed days of care (BDOC) requirement for this class were increased to 3 BDOC in a fiscal year from the previous requirement of one BDOC. Increasing the BDOC requirement more accurately identifies the patients that elected not to remain in the program for a reasonable period of time. Note that BDOC do not need to be consecutive but must occur in the same fiscal year in the Blind Rehabilitation bed section known as Treating Specialty “21”. Hepatitis C: The Clinical Case Registry (CCR) will be the official data source for Hepatitis?C patients receiving anti-viral drugs. Formerly, the diagnosis of Hepatitis C and anti-viral drugs were obtained from several different data sources. The transition to the CCR will improve the integrity of the data associated with patients receiving care for the condition of Hepatitis C. Compensation and Pension Exam Class: All patients presenting for C&P exams have a purpose of visit (POV) code 01 for the encounter. The longstanding VERA funding rules ensure that all patients presenting for C&P exams are VERA funded, including non-veterans and active military personnel. The change to the C&P classification criteria allows patients presenting for a C&P exam that meet the Vesting requirements to be placed in a Vested class, thereby ensuring that the C&P patient is funded at a Price no lower than Price Group 2 for the VERA 2012 Model. Prior to this change, patients presenting for a C&P exam that included a Vesting visit were retained in the C&P class. The intent of the change was to improve the funding associated with C&P exams. It should be noted that patients who are vested during a C&P exam that do not receive care in years subsequent to the vesting exam will be reverted to the C&P patient class in the rolling-three year model used to identify the Basic Vested population for VERA funding. This process ensures that these patients are not over funded in subsequent VERA models when their only care at the VHA was for the C&P exam. VERA 2011 Model: The 2011 Patient Classification system included four new classes to the Patient Classification Hierarchy chart, bringing the total VERA 2011 Patient classes to 58. The new classes include two new Complex Care class and two new Basic Vested classes as follows:Care Coordination Home Telehealth (CCHT) Non-Institutional Care (NIC) category of care in Complex Care;Care Coordination Home Telehealth (CCHT) Chronic Care Management (CCM) category of care in Basic Vested Care;Homeless Multiple Medical in Basic Vested Care;Homeless Chronic Mental Illness in Complex Care. Homelessness as a classification factor was included for the first time in the VERA 2011 Model. The process for establishing data sources to identify the homeless patient population is tracked and maintained in a Homeless Registry maintained at the ARC. The initial designation of homelessness was based on either of the following criteria in a given year: An ICD-9 diagnosis code of V60.0 (Lack of Housing). The V60.0 can only be entered as a secondary diagnosis code in a Patient Treatment File (PTF) or as a primary or secondary diagnosis code for an outpatient encounter in the National Patient Care Database (NPCD). Significant care for a major mental health or substance abuse diagnosis during the fiscal year that included care for homelessness. The precise classification criterion for the Homeless Multiple Medical Class and the Homeless CMI Class are documented on the corresponding page of this handbook. VERA 2010 Model: Patient Classification system includes several changes to the classification criterion from former VERA Models, to more accurately account for current clinical practice patterns within the VHA. In addition, it incorporates the changes made as a result of the CMS transition to Medicare Severity Diagnostic Related Groups (MS-DRGs). The changes are described below. For Complex Care Long Term Care:A new VERA Price Group (10A) and VERA patient class were added to categorize the Long Stay Patient population with greater than 90 bed days of care (BDOC) in a Community Living Center (CLC). The resource needs and costs of this patient population are significantly higher than the vast majority of VHA patients due to extensive inpatient stays in VHA’s CLCs. Patients in this patient class are not entitled to a High Cost payment in addition to this VERA Price. Price Group 10: Short Stay CLC Patient Class includes patients with 28 to 90 BDOC in a CLC.Price Group 8: Skilled Nursing and Rehab Class. Includes patients with 7 to 27 CLC BDOC with RUG scores for Rehabilitation, Rehabilitation and Extensive Services and Special Care. Price Group 8: Legacy LTC/Intermediate class. This class will include patients residing in an Intermediate bed setting for 31 BDOC. Include Telehealth Workload in the classification criteria for the Home Based Primary Care (HBPC) patient class and the Chronic Mental Illness (CMI) patient class Annual Retention Criteria. HBPC Patient class: Of the required 10 qualified home visits, five of these visits may be completed by Telehealth by videoconferencing, which is documented as DSS Clinic Stop 179 as a secondary clinic stop.The CMI Annual Retention Criteria identifies the minimum level of outpatient visits that a patient must receive to remain in the CMI patient class in the immediate subsequent year. Beginning with fiscal year 2008 workload, the required CMI visits will also include workload performed by Telehealth procedures, when precise Telehealth codes are documented as a secondary DSS Clinic Stop (CS). There are no restrictions on the maximum number of visits that can be performed by Telehealth. The following DSS CSs in the secondary position will count towards the required number of visits to retain the patient in the class. 179 Real-Time Videoconferencing Home Care, or Telehealth workload documented as the following corresponding clinic stops (CS 690 and 692 or 690 and 693) on the same date of care. The descriptions of the CS are as follows: 690: General Telehealth Real Time: records data at the patient’s site. 692: General Telehealth Real Time: provider at same station as patient.693: General Telehealth Real Time: provider NOT at same station as patient.Basic Care:Create History of Transplant in Multiple Problem Price Group 5. This will include post-organ transplant patients that are currently included in the Multiple Medical patient class when they receive anti-rejection drugs from the VHA and as of VERA 10, post-bone marrow transplant patients for five years following the bone marrow transplant. The Multiple Problem Price Group patient classes will recognize “significant levels” of outpatient care as seven (7) Relative Value Units (RVUs) designated as Work units. This value was previously 10 RVUs of “FAC” units, which did not sufficiently recognize the clinical component of the codes in former Patient Classification processes. In addition to changing to at least 7 Work RVUs, the Multiple Problem classes will now include patients with both inpatient care and significant levels of outpatient care (at least 7 Work RVUs) in a second Major Diagnostic Category (MDC). In prior VERA Models, outpatient care was only used for these classes in the absence of inpatient care. This change removes the longstanding “inpatient/outpatient rule” and removes any disincentive (perceived or otherwise) associated with providing outpatient care. Legally Blind patient class includes several additional diagnosis codes for Legal Blindness. Metastatic Cancer patient class will be modified to include metastatic cancer as a secondary diagnosis when a patient receives treatment for cancer as a principal diagnosis in the same year. The Compensation and Pension (C&P) patient class was revised to include all patients that present for a C&P exam in the given year. The Purpose of Visit (POV) field for the encounter documents that the patient presented for a C&P exam. Patients with a POV equal to “01” will no longer be placed in the Non-Vested patient class when they have not received a Vesting CPT code. The change ensures that the C&P patient class more accurately accounts for patients that present exclusively for a C&P exam during the year. The following classes from preceding VERA Models have been removed:All Long Term Care (LTC) classes in Critically Ill Price Group 10 that required a minimum of 31 LTC BDOC and were differentiated by Resource Utilization Group (RUG) scores. These classes included: Specialized Care, Rehabilitation, Physical, Behavioral and Clinically Complex. The Low Activities of Daily Living (ADL) LTC class in Price Group 8 is removed. The new LTC/Intermediate Class will capture most of the patients that qualified for this class due to BDOC in an intermediate treating specialty. VERA 2009 Model: The Home Based Primary Care (HBPC) patient class includes new DSS Clinic Stops to identify Psychologist workload (156) and Psychiatrist workload (157). VERA 2008 Model: Changes to the Patient Classification criteria included the following: Complex Care: The Transplant patient class was changed to a one year class from a three year class. In addition to the timeframe change, in years following a qualifying transplant, post transplant patients that receive specific anti-rejection drugs will fall no lower than the Multiple Medical patient class on the classification hierarchy. Post-transplant patients are identified by either the ARC transplant registry data for patients with a VHA provided transplant or by specific post-transplant diagnosis codes listed in the Multiple Medical patient class criteria. The post-transplant patient population includes patients whose transplant was VHA provided, as well as privately procured transplants. The Resident Assessment Instrument/ Minimum Data Set (RAI/MDS) was expanded to 53 new Resource Utilization Groups (RUG) from 44 in prior fiscal years. The nine new RUG scores identify patients in the Rehabilitation Long Term Care patient class that have received extensive rehabilitation services.Renamed the Heart Failure patient class to Acute Myocardial Infarction. No additional changes were made to the class criteria. VERA 2007 Model: Two new classes were added to the Patient Classification system in VERA 2007 bringing the total number of classes in the classification system to 55. The new classes include the two Multiple Sclerosis (MS) classes. The first identifies patients that received either inpatient or outpatient care for a diagnosis of MS. It is funded in Oncology/Infectious Dis./Legally Blind Price Group (#4). The second MS class includes patients that receive specific drugs and is funded in the Multiple Problem Price Group (#5). This class identifies patients who have received inpatient or outpatient care for MS plus have received at least a two month supply of specific High Cost drugs documented in the VHA Pharmacy Benefits Management (PBM) database during the given year. VERA 2006 Model: There were no changes to the VERA patient classification process from VERA 2005. VERA 2005 Model: Several refinements were made to the patient classification system for the VERA 2005 model following an extensive analysis of the VERA patient classification system. These changes include: Expand the number of classes in the patient classification system to 53 (VERA 2004 had 47 patient classes). Five of the new classes form a new Price Group titled Significant Diagnoses within Basic Vested Care. The sixth new Vested Care class identifies patients with a diagnosis (primary or secondary) of Legal Blindness. Reorder the patient classes within the classification hierarchy based on resource intensity and assign classes to appropriate VERA Price Groups. Add the new price group, Significant Diagnoses within Basic Care. In addition, consolidate the Basic Medical (#2) price group and Heart, Lung and Gastrointestinal (#4) price group into a single price group.Retain Vested homeless veterans who are part of the Seriously Mentally Ill (SMI) Special Disabilities population in the Acute Mental Diseases patient class, funded in the Mental Health Price Group (# 3). SMI homeless veterans have a major psychiatric diagnosis and at least 6 visits to a psychiatric clinic stop in a given year. At least one of these psychiatric visits was to a homeless outpatient clinic. Change the VERA Price Groups for the following classes: the HBPC class moves up to the Supportive Care Price Group (8) and the Stroke patient class moves down one price group to the Specialized Care PG (7). Exclude workload completed by Telehealth/telemedicine from the classification criteria for the Home Based Primary Care patient class and the Chronic Mental Illness patient classes. Modify the End Stage Renal Disease (ESRD) patient class criterion to include CPT code 90999 – unlisted dialysis procedure as a valid code indicating a dialysis treatment. VERA 2004 Model: The patient classification hierarchy had 47 classes in the classification system. VERA 2004 was the first model to include two sets of VERA 10 prices to account for the resource differences between patients in Enrollment Priority Groups 1-6 and 7&8. Eligibility for VERA funding was based on Health Eligibility Center (HEC) Enrollment Priority data, and all veterans were VERA-funded with the exception of veterans on Sharing Agreements or TRICARE. Prior VERA Models relied on Means Test data to determine eligibility for VERA-funding. VERA 2003 Model: The patient care funding component of the VERA 2003 model was expanded from three to ten price groups, and Means Tests were used to determine eligibility for VERA funding. In fiscal year 2003, outpatient data sets began to show evidence of Telehealth workload, recorded using primary as well as secondary clinic stop codes. Workload identified as Telehealth/telemedicine or care coordination did not count as a qualified visit for the Complex Care Home Based Primary Care (HBPC) patient class or as part of the Chronic Mentally Ill (CMI) annual retention criteria.VERA 2002 Model: The VERA Model contained 47 Patient classes and three VERA Price groups for Complex, Basic Vested and Basic Non-Vested patient classes. The Mental Health Intensive Case Management (MHICM) class was added to the classification hierarchy as a new outpatient chronic mental illness patient class. Vesting criteria was augmented to ensure that Vesting visits (vesting CPT codes) were completed by authorized providers. VERA 2001 Model: The Model contained 46 patient classes and three VERA Price Groups for Complex, Basic Vested and Basic Non-Vested care. Two new classes for Hepatitis C were added to the classification hierarchy; one in the Complex Care group for patients receiving drug therapy for their hepatitis condition, the other in the Basic Vested Care group. VERA 2000 Model: The VERA Model contained 44 patient classes and three price groups. The Non-vested patient class was created for “low intensity” outpatient users of the VHA healthcare system. Non-vested patient include patients receiving exclusively outpatient services that did not contain a primary care visit. VERA 1999: The Model contained 55 patient classes and three price groups. The new class, “single visit” was added to identify infrequent users of the VHA healthcare system. VERA 1998: The Model contained 54 patient classes and two price groups. The Blind Rehabilitation class was added to the classification hierarchy. In the 1997 model an adjustment was made for patients in Blind Rehabilitation programs. VERA 1997: The first VERA Model commenced in April 1997, half way through the fiscal year. VERA 07 contained 53 patient classes and an adjustment for patients treated in blind rehabilitation units. There were two price groups in the first VERA Model. The 4 Basic Non-Reliant ClassesCompensation and Pension (C&P) EvaluationEmployee/CollateralsNon-Vested PatientPharmacyCompensation and Pension (C&P) Exams XE "Compensation and Pension (C&P) Exams" (Class #3 in the Patient Classification hierarchy)Patient Class Overview:The Compensation and Pension (C&P) Exam patient class is based on coding criteria in the National Patient Care Database (NPCD) and the Fee Payment Files. This class includes patients who were not included in a higher class in the patient class hierarchy and whose only interaction with the VHA during a fiscal year is for a Compensation and Pension (C&P) Examination that did not include a level of primary care services that would Vest the patient. Beginning with the VERA 2012 Model, patients presenting for a C&P exam that received primary care services recognized as a Vesting exam were classified into the appropriate Vested patient class, which is no lower than Price Group 2 on the classification hierarchy chart. This process ensures that all patients receiving Vesting services are accurately funded in the VERA Model. Data Sources(s) and Class Criteria: The NPCD and the Fee Payment Files are the sources of data used to classify patients into the C&P Exam Patient class. The C&P Exam is coded as “01” in the ‘Purpose of Visit’ field in the NPCD. Patient receiving a C&P exam will fall no lower on the classification hierarchy than the C&P class. Patients presenting for a C&P exam will qualify for a class that is higher on the classification hierarchy when additional qualifying services are provided. For example, beginning with the VERA 2012 Model, C&P patients who receive a Vesting CPT code as part of their C&P exam are placed in the appropriate Basic Vested VERA class, which is no lower than Price Group 2. Care provided in the two immediate years following the Vesting visit will retain the patient in the appropriate Basic Class. This care includes all successfully transmitted encounters, including telephone encounters and secure messaging. NOTE: In subsequent VERA Models that use historical workload for funding purposes, Vested C&P patients that do not receive care in the second and/or third year following the vesting visit, will be represented in the C&P class. This process ensures that the VERA Model does not over-fund patients presenting for a C&P exam in a single year when they do not receive VHA care in subsequent years. Non-VA or Contracted Care: All non-VA care for C&P exams must be documented in the Fee Payment Files. Classification Criteria Changes for VERA 2013: None, however, VERA 2012 refinements to this class ensured that C&P patients that received primary care clinical services recognized as a Vesting visit were appropriately classified to the Basic Vested Patient Class in the year that the services were received. Encounter forms that document care, including care by telephone or secure messaging count as valid workload and will retain the patient in the Basic Vested class in the two subsequent classification years. Care Group and Price Group: The C & P patient class is part of the Basic Care, Price Group #1 - Non-reliant Care Price group. Non-veterans (including active military personnel) presenting for C&P exams are funded in VERA. Eligibility for VERA funding: All patients (including non-veterans and active military personnel) presenting for a Compensation and Pension (C&P) Exam are funded in the VERA Model. The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Non-veterans, including active military personnel presenting for C & P exams (documented as Purpose of Visit code 01) are funded in VERA at the Priority Group 7&8 Price. Classification Timeframe: Annual. Employee/Collaterals XE "Employee/Collaterals" (Class # 1 in the Patient Classification hierarchy)Patient Class Overview:The Employee/Collaterals patient class is not funded in the VERA Model. This class includes: (1) VA employees or collaterals of veterans who receive ambulatory care and/or consultation about health care services; (2) Non-Veterans, that may be from other federal agencies, Humanitarian, etc. Data Sources(s) and Class Criteria:The National Patient Care Database (NPCD) and the Fee Payment Files are the sources of data used to classify patients into the Employee/Collaterals patient class. The eligibility code status is screened for the non-veteran status. A collateral is a person related to or associated with a veteran receiving care from the VA, visiting a VA health care facility, or being visited by a VA staff member at a site away from the VA health care facility. In any event, a VA health care professional obtains or provides information to the collateral that will assist and/or support in the care of the patient. Non-VA or Contracted Care: All non-VA hospitalizations that are paid for by the VA must be recorded in a PTF. The PTF provides the diagnosis criteria for this patient class. Classification Criteria Changes for VERA 2013: There were no changes made to this class criterion. Care Group and Price Group: The VERA Model does not fund patients whose only interaction with the VHA meets the Employee/Collateral patient classification criteria for the 3-year timeframe. However, it is not uncommon for enrolled veterans to also be employees of the VHA. Basic care veterans who are also VA employees are VERA-funded if at any time during the fiscal years 2011, 2010 and/or 2009 they receive treatment as an enrolled veteran in addition to care as an employee. In such cases, the veteran’s 3-year workload will be distributed to the appropriate patient classes for each of the 3 years. Workload will be reflected in the Employee/Collateral patient class in the years that the patient received care exclusively as an Employee i.e. flu shot, and that portion of the patient’s Pro-rated Person (PRP) will be funded at Price Group 1 - Non-reliant Care price. (See Pro-Rated Person Tutorial on the ARC website for additional information on proportionate share.) Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Patients that are classified as Employee/Collaterals are not funded in the VERA Model. The only exception is when a patient is classified into a Basic care VERA-funded class during the other two years covered by the model. See paragraph above for details. Classification Timeframe: Annual. Non-Vested Patient Class XE "Non-Vested Patient Class" (Class # 4 in the Patient Classification hierarchy)Patient Class Overview:The Non-Vested patient class identifies patients that have received exclusively outpatient services during the classification year, and possibly during the prior two classification years as well. This class is intended to include patients who are receiving services from the VA but are not using the VA as their principal health care provider. To identify patients using the VHA as their principal health care provider, the VA must provide a detailed medical evaluation in an outpatient setting at least once during a 3-year period. This 3-year period includes the current classification year and the prior two classification years. A patient is placed in the Non-Vested patient class if during the specified 3-year period, s/he has not had: An inpatient admission (which includes a stay in an observation bed), orA detailed medical evaluation consisting of a minimum of a level-three evaluation and management (E & M) examination as determined by a specific list of Current Procedural Terminology (CPT) codes. (See next page for a complete listing of CPT Codes for Vesting.) Note that a Vesting CPT code must be administered by a clinician authorized to complete level-three evaluation and management exams. The list of authorized providers includes physicians (including residents), physician assistants, clinical nurse specialists and nurse practitioners. The ARC uses the data field known as “person class” to identify the provider/clinician. (See complete list of qualified vesting providers at ( )Data Source(s) and DataThe National Patient Care Database (NPCD) and the Fee Payment Files are the sources of data used to classify patients into the Non-Vested patient class. A patient is classified as Non-Vested when the data sets indicate that the patient has exclusively received outpatient care during the fiscal year, and has not received a Vesting CPT code by a Vesting provider during a 3-year timeframe. Note that a patient will not be vested by a telephone encounter. The patient must have a face-to-face visit to meet the vesting requirements. Note that the Patient Treatment Files are screened to ensure that the patient did not have an inpatient admission or stay in an observation bed during the fiscal year or the prior two classification years. Patients that have been admitted or placed in observation have received (at a minimum), the equivalent of a comprehensive history and physical, thereby fulfilling the Vesting requirement. Non-VA or Contracted Care: All Non-VA outpatient care that is documented in the Fee Payment Files is considered for the purpose of vesting. As such, a Vesting CPT code in the fee files indicating that a detailed history and physical occurred in a non-VA setting will move a patient from the Non-Vested class to a Basic Vested patient class. The specific class is contingent upon the patient's diagnosis. Vesting CPT codes performed in a non-VA setting are not screened for CMS providers. Criteria Changes to the Non-Vested patient class for VERA 2013: There were no changes to this patient class. Care Group and Price Group: Basic Care, Price Group #1 - Non-reliant Price Group. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual patient class. Patients are retained in the Non-Vested patient class for a single year. VERA 2013 Vesting CPT Codes XE "VERA 2012 Vesting CPT Codes" CPT Code CPT Code Description 90801 Psychiatric diagnostic interview examination including history, mental90802 Interactive Psychiatric diagnostic interview90805 Individual Psychotherapy, 20 - 30 minutes with Medical Evaluation (Amb)90807 Individual Psychotherapy > 45 minutes with Medical E and M90809 Individual Psychotherapy > 60 minutes with Medical E and M90813 Individual Psychotherapy, Interactive, > 45 minutes with Medical E and M90815 Individual Psychotherapy, Interactive, > 60 minutes with Medical E and M90817 Individual Psychotherapy, 20 - 30 minutes with Medical Evaluation (IP or Res)90819 Individual Psychotherapy, residential, > 45 minutes with Medical E and M90822 Individual Psychotherapy, residential, > 60 minutes with Medical E and M99203 Office/outpatient visit new patient, Level 399204 Office/outpatient visit, new patient, Level 499205 Office/outpatient visit, new patient, Level 599213 Office/outpatient visit, established patient, Level 399214 Office/outpatient visit, established patient, Level 499215 Office/outpatient visit, established patient, Level 599243 Office/outpatient consultation, Level 399244 Office/outpatient consultation, Level 499245 Office/outpatient consultation, Level 599283 Emergency department visit, Level 399284 Emergency department visit, Level 499285 Emergency department visit, Level 599343Home visit for evaluation and management, >45 minutes99344Home visit for evaluation and management, >60 minutes99345Home visit for evaluation and management, >75 minutes99349Home visit for evaluation and management, >40 minutes99350Home visit for evaluation and management, >60 minutes99385 Initial Preventive Visit with Comp history & Comp Exam, 18-3999386 Initial Preventive Visit with Comp history & Comp Exam, 40-6499387 Initial Preventive Visit with Comp history & Comp Exam, 65 and older99395 Periodic Preventive Visit with Comp history & Comp Exam, 18-3999396 Periodic Preventive Visit with Comp history & Comp Exam, 40-6499397Periodic Preventive Visit with Comp history & Comp Exam, 65 and older99455Work related or medical disability examination by treating physician99456Work related or medical disability examination by non-treating physicianVERA 2013 model uses Basic care workload from fiscal years 2011, 2010 and 2009. Basic care patients that have not had an inpatient admission or a Vesting CPT code during this timeframe are classified as Non-vested. Pharmacy XE "Pharmacy" (Class # 2 in the Patient Classification hierarchy)Patient Class Overview:The Pharmacy patient class includes patients whose only interaction with the VHA during the specified fiscal year is exclusively for pharmaceuticals. Patients included in this class have not had a clinical encounter (inpatient or outpatient) during the timeframe, but may have received certain prosthetic devices by mail. Data Sources(s) and Class Criteria:The primary data source for the Pharmacy (only) patient class is the Pharmacy Benefits Management (PBM) package in Hines, IL. This data is collected at the facility-level and includes pharmaceuticals distributed by the facilities and the Consolidated Mail-out Pharmacy (CMOP) program. The PBM forwards data to the ARC each month. At the end of the fiscal year, the final PBM data extract is cross-referenced to the Decision Support System (DSS) national data extract. Patients must be represented in both data extracts to be placed in the Pharmacy (only) patient class. Patients who are not included in both the PBM and DSS data extract are not placed in this patient class. Note that some of the patients in this class may also have received certain prosthetic (PRO) devices mailed to them from the Denver Distribution Center (DDC) or a local facility. Non-VA or Contracted Care: Does not apply to this patient class.Classification Criteria Changes for VERA 2013: There were no changes to the Pharmacy classification criteria for VERA 2013. Beginning with VERA 2002 model, the DSS National Data extract is used to validate patients in the Pharmacy patient class. Patients that are not represented in the DSS data are not placed in the Pharmacy patient class. Care Group and Price Group: The Pharmacy patient class is part of the Non-Reliant Care Price Group. Patients that are exclusively classified into Pharmacy (only) class for the specified 3-year timeframe covered in the VERA Model are not VERA-funded. The VERA 2013 model takes into account Basic Care workload performed in fiscal years 2009, 2010 and 2011. . Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. As a general rule, patients receiving exclusively pharmacy services with no other VHA care are not funded in the VERA Model. However, it is important to note that the VERA Model uses a 3-year proxy of VERA-eligible Basic Care patients. If at any time during the 3-year period the patient is classified into another funded Basic Care patient class, the patient is VERA-funded. In such instances, the patients’ 3-yr Pro-Rate Person (PRP) will be divided between the VERA-funded Basic Care patient class and Non-reliant Price Group based upon the proportionate costs in each Price Group. Classification Timeframe: Annual. The 29 Basic Vested Care Group ClassesAcute Mental DiseasePTSD - AcuteAcute Myocardial InfarctionPulmonary DiseaseAddictive DisordersRespiratory FailureCardiovascular Disease Care Coordination Home Telehealth – Chronic Care ManagementCentral Nervous SystemEar, Nose and ThroatEndocrine, Nutritional, Metabolic DisordersEpilepsy Gastroenterology DisorderHepatitis C without Anti-Viral TherapyHigh Cost ConditionsHigh Cost PneumoniaHistory of TransplantHIV+ Without ARV TherapyHomeless Multiple MedicalLegally BlindMedical + Psych or Substance AbuseMetastatic CancerMultiple MedicalMultiple SclerosisMultiple Sclerosis with PharmaceuticalsMusculoskeletal DisordersOncologyOther Acute DiseasesPsych + Substance AbuseAcute Mental Disease XE "Acute Mental Disease" (Class #13 in the Patient Classification hierarchy) Patient Class Overview:The Acute Mental Disease patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for treatment of acute mental disease. Data Source(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. The Acute Mental Disease patient class includes patients with a principal ICD-9 diagnosis in: MDC 19: Mental Diseases and Disorders DRGs: 876, 880-887 excluding inpatient care for ICD-9 309.8X Reaction Adjustment, which is mapped to the Posttraumatic Stress Disorder (PTSD) Acute patient class that is in a higher Price Group.Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG). DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) A patient with an inpatient principal diagnosis code within the criteria identified above will qualify for the Acute Mental Disease patient class. A patient with principal diagnoses in more than one MDC may qualify for a multiple diagnosis class that is higher on the classification hierarchy. Outpatient: The National Patient Care Database (NPCD) is the source of the primary outpatient ICD-9 diagnosis code(s) that identify the primary reason the patient presented for treatment. The Work Relative Value Unit (RVU) for clinical codes including CPT codes and HCPCS II codes are used to determine predominant outpatient diagnosis. If a patient receives outpatient services in more than one MDC, the predominant MDC is used in the classification process. The predominant diagnosis is determined by the cumulative sum of Work RVUs by diagnosis and is used for outpatient classification. These diagnosis codes also correlate to a specific MDC. (See Appendix B.) Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to this class criterion. Care Group and Price Group: Basic Vested Care; Price Group #3 – Mental Health. VERA-eligibility: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Acute Myocardial Infarction XE "Acute Myocardial Infarction" (Class # 29 in Patient Classification hierarchy)Patient Class Overview:The Acute Myocardial Infarction (Acute MI) patient class is based on principal diagnosis criteria. This Basic Care vested class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient care or outpatient care that resulted in an inpatient admission is for treatment of Acute Myocardial Infarction. B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. A change for the VERA 2013 classification process requires that a principal outpatient diagnosis of Acute Myocardial Infarction will only be included in this class when it results in an inpatient stay. Outpatient care alone does not qualify for this class. A patient is placed in the Acute MI patient class with a principal or secondary inpatient ICD-9 diagnosis code of: ICD-9 410.X1 Acute myocardial infarction, initial episode of care. (Note the “X” in the diagnosis code allows any number in its place, and therefore many different ICD-9 diagnosis codes are possible.) Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal or secondary diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. Outpatient: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes as well as the CPT or HCPCS Level II codes that identify the specific services outpatient services provided. The outpatient diagnosis codes are mapped to DRGs, which aggregate up to Major Diagnostic Categories (MDC). (See Appendix B for precise mapping.) The RVUs associated with the diagnosis codes noted above must be predominant to qualify for the Acute Myocardial Infarction patient class. Patients with outpatient encounters (including emergency room visits) for Acute MI will be screened to determine whether an admission occurred on the same day of care. Note that in such circumstances, the admitting diagnosis should, but does not necessarily include the required Acute MI. For this reason, the outpatient encounter date is matched to inpatient admission dates to qualify for this class. This class is intended to capture patients requiring inpatient care for the treatment of Respiratory Failure codes noted above. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: This class was modified to exclude outpatient care for the diagnosis code 410.X1 that did not result in an inpatient admission on the same day of care. Admission dates on PTFs are screened to determine if the outpatient encounter culminated in an inpatient stay. Note that the inpatient diagnosis code may not have followed an outpatient encounter that included the diagnosis code for Acute Myocardial Infarction (ICD-9 410.X1). Care Group and Price Group: Basic Vested Care; Price Group #6 - Significant Diagnoses. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Addictive Disorders XE "Addictive Disorders" (Class #14 in the Patient Classification hierarchy)Patient Class Overview:The Addictive Disorders patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for addictive disorder treatment. Data Sources(s) and Class Criteria:This Basic Vested patient class uses the patient's principal diagnosis as the source of classification criteria. A patient with a principal ICD-9 diagnosis in the following group is included in the Addictive Disorders Patient class. MDC 20: Alcohol/Drug use and Alcohol/Drug Induced Mental Disorders (DRGs: 894-897)Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG). DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) Outpatient: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes as well as the CPT or HCPCS Level II codes that identify the specific services outpatient services provided. The outpatient diagnosis codes are mapped to DRGs, which aggregate up to Major Diagnostic Categories (MDC). (See Appendix B for precise mapping.) If a patient has predominant workload in MDC 20, the patient is placed in the Addictive Disorders class.Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to this class criterion. Care Group and Price Group: Basic Vested Care; Price Group #3 – Mental Health. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Cardiovascular Disease XE "Cardiovascular Disease" (Class #10 in the Patient Classification hierarchy)Patient Class Overview:The Cardiovascular Disease patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for Diseases and Disorders of the Circulatory System.Data Sources(s) and Class Criteria: This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. A patient with a principal ICD-9 diagnosis in the following DRGs is included in the Cardiovascular Disease Patient class.MDC 5: Diseases and Disorders of the Circulatory SystemDRGs: 215-264, 280-316 (Note the following exception: - ICD-9 410.X1 qualifies for the Acute Myocardial Infarction patient class when a patient is admitted for this diagnosis.) Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG.) DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) The DRGs for this patient class are listed below. Outpatient: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes as well as the CPT or HCPCS Level II codes that identify the specific services outpatient services provided. The outpatient diagnosis codes are mapped to DRGs, which aggregate up to Major Diagnostic Categories (MDC). (See Appendix B for precise mapping.) If a patient has predominant workload in the DRGs noted above, the patient is placed in the Cardiovascular Disease patient class.Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to this class criterion. However, note that certain cardiovascular diagnoses within MDC 5 are part of the Significant Diagnoses Price Group (6) classes. Care Group and Price Group: Basic Vested Care; Price Group #2 - Basic Medical/Heart, Lung, Gastrointestinal Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Care Coordination Home Telehealth – Chronic Care Management XE "Care Coordination Home Telehealth –Chronic Care Management" (Class # 22 in the Patient Classification hierarchy)Patient Class Overview:The Care Coordination Home Telehealth (CCHT) – Chronic Care Management (CCM) patient class is based on a CCHT?Continuum of Care assessment performed by a CCHT care coordinator and a minimum?of?three months of CCHT care of the patient during the fiscal year.? This was a new class for the Model supported by the Office of Telehealth Services (OTS), which has resulted in a reduction in bed days of care and admissions amongst Veteran patients managed in CCHT programs.? Data Sources(s) and Class Criteria:This Basic Vested patient class is based on two factors including a CCHT Continuum of Care assessment which places a patient into the Chronic Care Management (CCM) category of care and a minimum of three months of CCHT care (documented using the Home Telehealth Non-Video monitoring DSS stop code) during the fiscal year while the patient is enrolled in the CCHT program.? The designation of patients into the CCM category of care is entered by a CCHT Care Coordinator into the CCHT vendor databases, which are maintained in the CCHT Vendor cube on the VSSC website. ?CCHT Assessment:? The CCHT assessment tool, otherwise known as the Continuum of Care Form (CCF), is located in Computerized Patient Record System (CPRS) and must be completed by a CCHT care coordinator. The assessment may occur while the patient is in an inpatient status, but more often occurs during an outpatient encounter.? The results of this assessment are documented in CPRS and are subsequently entered into the CCHT vendor data base and transmitted to the VSSC.? Patients with a category of care of “Chronic Care Management” (CCM)?are candidates for this class if they meet the annual workload requirements in “2” below.??? In addition to designation of the CCM Category of Care, outpatient workload encounters documented in the National Patient Care Database (NPCD) must include at least three separate months of CCHT care (using the DSS Primary stop code 683 described below).? Although the monthly encounters are not required to occur in immediate successive months, they must occur during the fiscal year while the patient is in an “Enrolled” status. Encounters documented in days after the date the patient has been dis-enrolled from the CCHT program will not count towards the required three encounters.?? DSS CS 683:? Home Telehealth Non-Video Monitoring(Primary clinic stop)Records workload by VA health care professionals using non-video electronic in-home messaging devices for the remote monitoring of patients on a regular basis.? This code is reported once each calendar month per patient enrolled in CCHT that uses a messaging device. Not to be used to document workload for patients using other technology devices that does not have in-home messaging functionality.? For use by approved Care Coordination Home Telehealth (CCHT) Programs only.? ???Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload. Non-VA or Contracted Care:? There is no non-VA source for this patient class.? All CCHT assessments must be completed by CCHT care coordinators within the VHA and the designation of the CCM category of care must be evident in the NPCD supported by the VSSC. ??Classification Criteria Changes for VERA 2013: None. This was is a new class for VERA 2011.??Note that there is also a Complex Care class for patients with a CCHT Non-Institutional Care (NIC) category of care that requires three separate months of CCHT care in the fiscal year. Care Group and Price Group: Basic Vested Care; Price Group #5, Multiple Problem.? Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Central Nervous System XE "Central Nervous System" (Class # 9 in the Patient Classification hierarchy)Patient Class Overview:The Central Nervous System patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for treatment of the Central Nervous System. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. An inpatient with a principal ICD-9 diagnosis in the following DRGs is included in the Central Nervous System patient class: MDC 1: Diseases and Disorders of the Nervous System(DRGs: 20-42, 52-103)MDC 2: Diseases and Disorders of the Eye(DRGs: 113-117, 121-125)Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9-CM codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG.) DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs.) (See Appendix B for the ICD-9-CM to MDC relationship.) The DRGs for this patient class are listed below. Outpatient: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes as well as the CPT or HCPCS Level II codes that identify the specific services outpatient services provided. The outpatient diagnosis codes are mapped to DRGs, which aggregate up to Major Diagnostic Categories (MDC.) (See Appendix B for precise mapping.) If a patient has predominant workload in the DRGs noted above, the patient is placed in the Central Nervous System patient class.Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to this class criterion. Care Group and Price Group: Basic Vested Care; Price Group #2, Basic Medical/Heart, Lung, Gastrointestinal.Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Ear, Nose, and Throat XE "Ear, Nose, and Throat" (Class # 6 in the Patient Classification hierarchy)A. Patient Class Overview:The Ear, Nose, and Throat patient class is based on diagnosis criteria. This class includes patients who were not included in any patient class higher in the hierarchy and whose inpatient or outpatient care is for Diseases and Disorders of the Ear, Nose, Mouth and Throat. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. A principal ICD-9 diagnosis in the following DRGs is included in the Ear, Nose and Throat Patient Class.MDC 3: Diseases and Disorders of the Ear, Nose, Mouth and ThroatDRGs: 129-139, 146-159 Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG.) DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) Outpatient: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes as well as the CPT or HCPCS Level II codes that identify the specific services outpatient services provided. The outpatient diagnosis codes are mapped to DRGs, which aggregate up to Major Diagnostic Categories (MDC). (See Appendix B for precise mapping.) If a patient has predominant workload in the DRGs noted above, the patient is placed in the Ear, Nose and Throat patient class. Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to this class. Care Group and Price Group: Basic Vested Care, Price Group #2 - Basic Medical/Heart, Lung, Gastrointestinal. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Endocrine, Nutritional, Metabolic Disorders XE "Endocrine, Nutritional, Metabolic Disorders" (Class # 7 in the Patient Classification hierarchy)Patient Class Overview:The Endocrine, Nutritional, Metabolic Disorders (Endo, Nutr. Metab. Disorders) patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for treatment of endocrine, nutritional, metabolic, kidney, reproductive system, and childbirth-related care. B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. The patient class is determined when principal diagnosis code(s) are mapped to a Medicare Severity Diagnostic Related Group (MS-DRG.) MS-DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) The DRGs for this patient class are listed below. The Endo Nutr Metab Disorders patient class includes patients with a principal ICD-9 diagnosis in:MDC 10: Endocrine, Nutritional and Metabolic Diseases and Disorders; DRGs: 614-630, 637-645MDC 11: Diseases and Disorders of the Kidney and Urinary Tract; DRGs: 652-675, 682-700MDC 12: Disease and Disorders of the Male Reproductive System; DRGs: 707-718, 722-730MDC 13: Diseases and Disorders of the Female Reproductive System; DRGs: 734-750, 754-761 MDC 14: Pregnancy, Childbirth and the Puerperium; DRGs: 765-770, 774-782MDC 15: Newborns and Other Neonates; DRGs: 789-795Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 diagnosis codes. Outpatient: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes as well as the CPT or HCPCS Level II codes that identify the specific services outpatient services provided. The outpatient diagnosis codes are mapped to DRGs, which aggregate up to Major Diagnostic Categories (MDC). (See Appendix B for precise mapping.) If a patient has predominant workload in the DRGs noted above, the patient is placed in the Endo Nutr Metab Dis. patient class. Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: No changes were made to this class criterion. Care Group and Price Group: Basic Vested Care, Price Group #2 - Basic Medical/Heart, Lung, Gastrointestinal. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Epilepsy XE "Epilepsy" (Class # 19 in the Patient Classification hierarchy)A. Patient Class Overview:The Epilepsy patient class is based on diagnosis criteria. This class includes patients who were not included in any patient class higher in the hierarchy and whose inpatient or outpatient care is for Epilepsy. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis in either inpatient or outpatient care. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. This class is based on the diagnosis code Epilepsy ICD-9 345.XX and does not consider the preponderance of outpatient workload in the classification process. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG). DRGs are aggregated to one of 25 mutually exclusive Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) Outpatient: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes. A primary outpatient diagnosis code of ICD-9 345.XX will qualify for this patient class. If a patient has predominant workload in the ICD-9 code 345.XX, the patient is placed in the Epilepsy patient class. Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: This is a new patient class for VERA 2013. Care Group and Price Group: Basic Vested Care, Price Group #4 – Oncology/Inf. Dis/Blind Rehab/Epilepsy. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Gastroenterology Disorder XE "Gastroenterology Disorder" (Class # 11 in the Patient Classification hierarchy)Patient Class Overview:The Gastroenterology Disorder patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for gastroenterology treatment. B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. The Gastroenterology Disorder patient class includes principal ICD-9 diagnosis in the following DRGs: MDC 6:Diseases and Disorders of the Digestive System(DRGs: 326-358, 368-395)MDC 7: Diseases and Disorders of the Hepatobiliary System and Pancreas(DRGs: 405-425, 432-446 excluding specific Hepatitis C diagnoses listed in Hep. C classes)Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Medicare Severity-Diagnostic Related Group (DRG). MS-DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) Outpatient: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes as well as the CPT or HCPCS Level II codes that identify the specific services outpatient services provided. The outpatient diagnosis codes are mapped to DRGs, which aggregate up to Major Diagnostic Categories (MDC). (See Appendix B for precise mapping.) If a patient has predominant workload in the DRGs noted above, the patient is placed in the Gastroenterology Disorder class.Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to this class criterion. Care Group and Price Group: Basic Vested Care, Price Group #2 - Basic Medical/Heart, Lung, and Gastrointestinal. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Hepatitis C without Anti-Viral Therapy XE "Hepatitis C without Anti-Viral Therapy" (Class # 17 in the Patient Classification hierarchy)Patient Class Overview: The Hepatitis C+ without Anti-Viral (AV) Therapy patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy. Specifically, Hepatitis C patients must be: Identified in the Clinical Case Registry (CCR), which is the official data source designed to support patient safety, quality of care and population health management for Veterans with hepatitis C and/or Human Immunodeficiency Virus (HIV) infection., and Received inpatient care or outpatient care for Hepatitis C. Data Sources(s) and Class Criteria:Patient Identification: The following data sources are used to identify Hepatitis C positive patients:Clinical Case Registry (CCR): The CCR is the official database that identifies patients that have tested positive for Hepatitis C. The classification criteria for the Basic and Complex Hepatitis C patient classes requires that all patients with Hepatitis C be registered in the Clinical Case Registry (CCR), in accordance with the VHA Directive 2011-026. This ensures that the VERA Patient Classification process complies with the VHAs policy and procedures for documenting Hepatitis C. Note that the directive requires each facility Director to designate a local CCR coordinator to support the hepatitis C and HIV registries. The ARC receives quarterly updates to the CCR extracts that is provided to the ARC each quarterOnce identified in the CCR, specific levels of care for the treatment of Hepatitis C are required each year.Inpatient care: The Patient Treatment File (PTF) N501 episode segments are the source of inpatient identification. Inpatient care with a principal diagnosis code from below, or secondary ICD-9 diagnosis code where the principal is from MDC 7. ICD-9 Diagnosis: 070.41 Acute hepatitis C with hepatic coma *070.44 Chronic hepatitis C with hepatic coma070.51 Acute hepatitis C without mention of hepatic coma *070.54 Chronic hepatitis C without mention of hepatic coma070.70 Unspecified viral hepatitis C without hepatic coma *070.71 Unspecified viral hepatitis C with hepatic comaV02.62 Hepatitis C carrierOutpatient Care: The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes. Outpatients must have at least two outpatient visits with a primary ICD-9 diagnosis listed above in the fiscal year. The required outpatient encounters can include telephone care. Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: Non-VA care does not qualify for this patient class. Classification Criteria Changes for VERA 2013: Beginning with VERA 2013, all patients is this class must be identified in the CCR. The CCR does not identify non-VA care for Hepatitis C. Care Group and Price Group: Basic Vested Care, Price Group #4 – Oncology/Infectious Disease/Legally Blind. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. High Cost Conditions XE "High Cost Conditions" (Class #33 in Patient Classification hierarchy)Patient Class Overview:The High Cost Conditions patient class is based on principal or secondary inpatient diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient care is for treatment of specific conditions identified by ICD-9 diagnosis code below. Outpatient care for the corresponding diagnosis codes is included only when the outpatient encounter culminates in an admission on the same day of care as the outpatient encounter. B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal or secondary inpatient diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. The diagnoses codes for the High Cost Conditions class include: ICD-9 CodeDescription 996.X to 996.XXComplication of Surgical and Medical Care997.X to 997.XXComplications affecting specified body systems998.X to 998.XX Other complications of proceduresNote: The “X” variable in the diagnosis code allows any number in its place. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. Unlike the majority of VERA patient classes that are defined by DRGs that map to one of 25 mutually exclusive major diagnostic categories (MDCs), the High Cost Conditions include precise diagnoses noted above indicating specific complications of care that map to many different MDCs. Any of the High Cost Conditions diagnosis codes above documented as either a principal or secondary diagnosis code in the PTF N501 segment qualifies for this patient class. Outpatient: Outpatient encounters for High Cost Conditions that do not result in an inpatient admission do not qualify for this class. The National Patient Care Database (NPCD) is the source of the primary ICD-9 diagnosis codes for outpatient care. Patients with outpatient encounters for High Cost Conditions diagnosis codes that are also admitted to inpatient care on the same day of care will qualify for this class. This class is intended to capture patients requiring inpatient care for the treatment of High Cost Conditions noted above. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes in the 501 segment. Note: Secondary diagnosis codes are not always evident in the Fee Payment files, so a Non-VA PTF would be essential in such circumstances. Classification Criteria Changes for VERA 2013: This class was modified to include secondary inpatient diagnosis codes documented in the N501 segment because coding requirements often require these codes to be listed as secondary when other conditions are evident. In addition, outpatient care for these primary diagnosis codes that does not culminate in an inpatient stay will no longer qualify for this patient class. In prior years, outpatient care alone qualified for this class. Care Group and Price Group: Basic Vested Care; Price Group #6 - Significant Diagnoses. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. High Cost Pneumonia XE "High Cost Pneumonia" (Class # 32 in the Patient Classification hierarchy)Patient Class Overview:The High Cost Pneumonia patient class is based on principal or secondary inpatient diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient care is for treatment of specific conditions identified by ICD-9 diagnosis code below. Outpatient care for the corresponding diagnosis codes is included only when the outpatient encounter culminates in an admission on the same day of care as the outpatient encounter. Outpatient care alone does not qualify for this class. B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient’s principal or secondary diagnosis for inpatient care. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. Patients with the following principal diagnoses are placed in the High Cost Pneumonia class. ICD-9 Code(s)Description 482.X to 482.XXOther bacterial pneumonia507.0Pneumonitis due to inhalation of solids or liquids038.X to 038.XXSepticemia785.59 Shock, other.Note: The “X” variable in the diagnosis code allows any number in its place. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal and secondary diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. Unlike the majority of VERA patient classes that are defined by DRGs that map to one of 25 mutually exclusive major diagnostic categories (MDCs), the High Cost Pneumonia isolates specific types of pneumonia for this patient class. Outpatient: Outpatient encounters for High Cost Pneumonia that do not result in an inpatient admission do not qualify for this class. The National Patient Care Database (NPCD) is the source of the primary ICD-9 diagnosis codes for outpatient care. Patients with outpatient encounters for High Cost Pneumonia diagnosis codes that are also admitted to inpatient care on the same day of care will qualify for this class. This class is intended to capture patients requiring inpatient care for the treatment of High Cost Pneumonia noted above. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes in the 501 segment. Note: Secondary diagnosis codes are not always evident in the Fee Payment files, so a Non-VA PTF would be essential in such circumstances. Classification Criteria Changes for VERA 2013: This class was modified to include secondary inpatient diagnosis codes documented in the N501 segment because coding requirements often require these codes to be listed as secondary when other conditions are evident. In addition, outpatient care for these primary diagnosis codes that does not culminate in an inpatient stay will no longer qualify for this patient class. In prior years, outpatient care alone qualified for this class. Care Group and Price Group: Basic Vested Care; Price Group # 6 - Significant Diagnoses. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. History of Transplant XE "History of Transplant" (Class # 27 in the Patient Classification hierarchy)Patient Class Overview:The History of Transplant patient class is based on several factors that identify patients with a precise diagnosis code indicating a history of an organ transplant or patients that have received a VHA-provided bone marrow transplant within the past five years. This class includes patients who were not included in a patient class higher in the classification hierarchy. B. Data Sources(s) and Class Criteria:This Basic Vested patient class uses the patient's principal or secondary diagnosis as the principal source of classification criteria. In addition to specific diagnosis codes, VHA historical data containing information on VHA provided transplants for the prior five fiscal years is screened to identify post transplant patients. The Inpatient Encounter (IE) file is also screened for this patient class. Post-organ transplant Patients: Patients that have received a qualifying organ transplant in a prior year that present for treatment and receive specific anti-rejection drugs documented in the VHA Pharmacy Benefits Management (PBM) database are placed in this class. The list of qualifying anti-rejection drugs includes: Azathioprine; Cyclosporine (oral or intravenous); Mycophenolate Mofetil; Mycophenolic Acid; Sirolimus and Tacrolimus. The population of former organ transplant patients (also known as post-transplant patients) includes: 1) Patients that received a transplant of the heart, lung, liver, or kidney paid for or provided by the VHA within the last five fiscal years and/or2) Patients* with a principal or secondary ICD-9 diagnosis code (inpatient or outpatient) listed below indicating a specific organ transplant in a prior year: V42.0????Kidney replaced by transplant V42.1??? Heart replaced by transplant V42.6??? Lung replaced by transplant V42.7??? Liver replaced by transplant V42.83 ?Pancreas replaced by transplant ?*Note that the transplant may have been paid for or provided by the VHA or privately procured.??Post- Bone Marrow Patients: In addition to the post-Organ Transplant Patients that receive anti-rejection medications from the VHA in years following the organ transplant, beginning with FY 2008 (VERA 2010) the History of Transplant class will include post-Bone Marrow Transplant patients for the immediate five years following the VHA-provided Bone Marrow transplant procedure. Post-bone marrow transplant patients must have received the transplant within the VHA, as VHA historical data will be used to identify this patient population. Furthermore, anti-rejection drugs are not a classification factor for post-bone marrow patients as these patients typically do not require these medications. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a primary and four secondary diagnosis codes. Note that the V-codes indicating an organ transplant may be a secondary ICD-9 diagnosis code. Classification Criteria Changes for VERA 2013: There were no changes for VERA 2013. This was a new class for VERA 2010. Post-organ transplant patients that received anti-rejection drugs were formerly included in the Multiple Medical patient class. Post-bone marrow patients were added to this class beginning with VERA 2010 model. Care Group and Price Group: Basic Vested Care; Price Group #5 – Multiple Problem. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. HIV+ without ARV Therapy XE "HIV+ without ARV Therapy" (Class # 15 in the Patient Classification hierarchy)Patient Class Overview: The Clinical Case Registry: HIV (CCR:HIV) is the ARC's data source for identifying all HIV patients. The CCR consists of patients with an ICD-9 diagnosis code 042 that have tested positive for the HIV infection. The HIV coordinator at each facility populates the registry which captures service utilization information, including pharmacy prescriptions and some laboratory test results. In addition, patients are categorized by disease severity, based on CD4+ cell count, CD4 percentage, and by the presence of an AIDS-defining opportunistic infection (OI). HIV infection is defined as having a positive blood test for HIV infection (two positive ELISAs and a confirmatory Western Blot)--this is a laboratory standard for reporting a positive result from a serum sample and does not require a second sample. {Appendix, MMWR, December 10,1999, Vol. 48/RR-13}. An HIV patient is placed in the Basic care patient class, "HIV+ without Antiretroviral (ARV) Therapy" if s/he is identified in the CCR:HIV and has NOT received ARV therapy during the classification year NOR has a diagnosis of AIDS OI. Patients with a diagnosis of AIDS OI are placed in the Complex class,” AIDS or HIV + w/ Anti Retro-Viral Therapy.” Data Sources(s) and Class Criteria:The Clinical Case Registry: HIV (CCR:HIV) is the ARC's primary data source for all HIV patients. Each year, the ARC receives data from the National CCR, compiled from the local CCR: HIVs. Patients are entered into the local CCR: HIV by the facility's HIV coordinator based upon the diagnosis of HIV infection. In addition, ICD-9 diagnosis code 042 is used in the classification process. Patients with an AIDS defining opportunistic infection are classified into the Complex care class, “AIDS or HIV+ with Anti Retroviral (ARV) Therapy.” Antiretroviral (ARV) therapy use is documented in the National CCR and can be confirmed by pharmacy benefits management (PBM) data. HIV patients receiving ARVs during the classification year are also classified as "HIV with ARV" in the Complex Care group. The HIV+ without ARV Therapy patient class includes principal ICD-9 diagnosis codes in the following DRGs: MDC 25: Human Immunodeficiency Virus Infections (DRGs 969-970, 974-977) Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG). DRGs are aggregated to one of 25 mutually exclusively major diagnostic categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) Outpatient: The National Patient Care Database (NPCD) is the source of the primary outpatient ICD-9 diagnosis code(s) that identify the primary reason the patient presented for treatment. The Work Relative Value Unit (RVU) for clinical codes including CPT codes and HCPCS II codes is used to determine predominant outpatient diagnosis. If a patient receives outpatient services in more than one MDC, the predominant MDC is used in the classification process. The predominant diagnosis is determined by the cumulative sum of Work RVUs by diagnosis and is used for outpatient classification. These diagnosis codes also correlate to a specific MDC. (See Appendix B.) Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes, which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: No changes to this patient class criterion. Care Group and Price Group: Basic Vested Care, Price Group #4 – Oncology/Infectious Disease/Legally Blind. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Permanent classification. Patient remains in this patient class in subsequent classification years unless the patient qualifies for a class that is higher on the classification hierarchy.Homeless Multiple Medical XE "Homeless Multiple Medical" (Class #24 in Patient Classification hierarchy)Patient Class Overview:The Homeless Multiple Medical patient class was a new class for the VERA 2011 Model designed to identify homeless patients that receive significant levels of scheduled outpatient services during a fiscal year. The significant levels of care must be for outpatient services provided for at least one major body system, otherwise identified as a Major Diagnostic Category (MDC) and excludes workload provided in the VHA and non-VA Emergency Department and Urgent Care. This class includes patients who were not included in a patient class higher in the classification hierarchy. A Homeless Registry will be developed in fiscal year 2011 to track homeless patients. Data Sources(s) and Class Criteria: The Homeless Multiple Medical patient class includes patients that are 1) Designated as Homeless and 2) Receive significant outpatient services in a given fiscal year. The designation of homeless as a patient classification factor began with the VERA 2011 Model. The process for documenting the homeless patient population is evolving and will ultimately be tracked and maintained in a Homeless Registry that will be established in fiscal year 2011. Homeless: For the VERA 2013 Model, the designation of homeless was based on either of the following: An ICD-9 diagnosis code of V60.0 (Lack of Housing) at least once during fiscal year 2009. The V60.0 code must be documented as a secondary diagnosis code in either a Patient Treatment File (PTF) for inpatient care or as a primary or secondary code in the National Patient Care Database (NPCD) for an outpatient encounter. The V60.0 code needs only to appear once during the fiscal year for the patient to be considered homeless, orTreatment for a major mental health or substance abuse diagnosis during the fiscal year that included care for homelessness. The precise homeless services included: An inpatient stay of at least one night in: Treating Specialty 28: Homeless CMI (HCMI) CWT/TR or Treating Specialty 37: Homeless Dom. Outpatient care in any of the following DSS Clinic Stops: DSS Clinic Stop 528: Telephone/Homeless Chronically Mentally Ill (HCMI)DSS Clinic Stop 529: Healthcare for Homeless Veterans (HCHV)/HCMIDSS Clinic Stop 590: Community Outreach Homeless. Beginning with FY2009, a patient meeting the definition of homeless noted above will retain the designation for the two immediate subsequent years, with or without additional documentation of codes indicating homelessness. Significant Outpatient Care: In addition to the designation of Homeless, the patient must have received significant outpatient care in at least one Major Diagnostic Category (MDC) during the fiscal year. Significant care is defined as at least 7 Work Relative Value Units (RVUs) associated with the outpatient primary diagnosis code(s). The RVUs represent the cumulative work values associated with CPT and HCPCS level II codes. However, RVUs associated with workload provided in the Emergency Department or Urgent Care (DSS Clinic Stop 130 and 131 respectively for VHA care) is not included in the cumulative sum of Work RVUs. Finally, note that the V60.0 code does not need to be part of all encounters for the given fiscal year. The National Patient Care Database (NPCD) is the source of the primary and secondary outpatient ICD-9 diagnosis codes, which map to MDCs. (See Appendix B.) Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. Non-VA workload documented in the Fee Payment files for outpatient care will be used to determine significant outpatient workload associated with the principal diagnosis. The coding rules require homelessness (V60.0) to be listed as a secondary inpatient diagnosis code. Classification Criteria Changes for VERA 2013: None. This was a new class for VERA 2011, developed to recognize significant levels of outpatient care provided to the homeless population. A National Homeless registry was developed in FY ? 2011 to track the homeless population. Care Group and Price Group: Basic Vested Care, Price Group # 5 - Multiple Problem. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Note that beginning with FY2009, a patient designated as homeless (noted above) will retain the designation for two subsequent years, with or without additional documentation of codes indicating homelessness in the two subsequent years. Legally Blind XE "Legally Blind" (Class # 16 in Patient Classification hierarchy)Patient Class Overview:The Legally Blind patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care indicates that the patient has specific types of legal blindness. B. Data Sources(s) and Class Criteria:Although Basic Vested Patient classes typically use the patient's principal diagnosis as the source of classification criteria, this class includes patients with a diagnosis code for Legal Blindness in the N501 episode segment in both the principal AND secondary location. Unlike the majority of VERA patient classes that are defined by one of 25 mutually exclusively major diagnostic categories (MDCs), the Legally Blind patient class is based on specific principal or secondary ICD-9 diagnosis codes:ICD-9 Codes for Legal Blindness369.01 to 369.08 Better eye: total vision impairment; lesser eye: vision impairment (qualified by precise code). 369.11 Better eye: severe vision impairment; lesser eye: blind, not further specified369.12 Better eye: severe vision impairment; lesser eye: total vision impairment*369.13 Better eye: severe vision impairment; lesser eye: near-total vision impairment*369.14 Better eye: severe vision impairment; lesser eye: profound vision impairment*369.22 Better eye: severe impairment; lesser eye: severe impairment*369.4 Legal Blindness*Indicates a newly added ICD-9 diagnosis codes beginning with VERA 2010. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. Outpatient:A primary or secondary outpatient diagnosis code of Legal Blindness from the list above will result in classification into the Legally Blind. The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes. Note that a patient receiving significant levels of workload in more than one MDC may qualify for one of the combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes, which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: No changes. Additional diagnosis codes for legal blindness were added for the 2010 Model. Newly added codes are marked by *. Care Group and Price Group: Basic Vested Care; Price Group #4 - Oncology/Infectious Disease/Legally Blind. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Medical + Psych or Substance Abuse XE "Medical+Psych/Substance Abuse" (Class # 21 in the Patient Classification hierarchy)Patient Class Overview:The Medical +Psych or Substance Abuse patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for both medical and mental health problems. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. The Medical +Psych or Substance Abuse patient class includes patients that during a fiscal year have a principal inpatient diagnosis or significant outpatient workload in a medical MDC as well as either MDC 19 or MDC 20. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG.) DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) Outpatient:Outpatient care is assessed in the classification process to determine whether the patient received significant levels of outpatient services. In such instances, all outpatient primary diagnosis codes are reviewed. To qualify for this patient class a patient must have significant outpatient care for ICD-9 diagnoses codes associated with at least one medical MDC, and one ICD-9 diagnosis in MDC 19 or MCD 20. Patients qualify for the Medical + Psych or Substance Abuse patient class when they have significant outpatient care (defined as at least 7 Work RVUs) in both a medical MDC and 7 Work RVUs in either MDC 19 or MDC 20. The RVUs represent the cumulative work values associated with CPT and HCPCS level II codes. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes to this class for VERA 2013. Beginning with VERA 2010, this class uses at least 7 Work RVUs to document significant outpatient care in a single Major Diagnostic Category (MDC). Care Group and Price Group: Basic Vested Care, Price Group #5 - Multiple Problem. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: AnnualMetastatic Cancer XE "Metastatic Cancer" (Class #30 in Patient Classification hierarchy)Patient Class Overview:The Metastatic Cancer patient class is based on principal and secondary diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for treatment of a specific diagnosis code for a malignant neoplasm. B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis and secondary diagnosis, as coding rules may require that these diagnoses be identified as a secondary diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. Unlike the majority of VERA patient classes that are defined by DRGs within one of 25 mutually exclusively major diagnostic categories (MDCs), the Metastatic Cancer patient class is based exclusively on a specific principal diagnosis code from the list below. If the diagnosis code is in the secondary position, the patient must also receive treatment for a primary diagnosis code of cancer (ICD-9 140 to 208.XX) in the same fiscal year to qualify for this class. ICD-9 CodeDescription 196.X to 196.X Secondary and unspecified Malignant neoplasm of lymph nodes197.X to 197.X Secondary malignant neoplasm of respiratory and digestive systems198.X to 198.XXSecondary malignant neoplasm of other specified sitesNote: The “X” variable in the diagnosis code allows any number in its place. Also, if the diagnosis above is listed as a secondary diagnosis code the patient must receive at least one primary diagnosis code for cancer in the given fiscal year. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. Outpatient: The National Patient Care Database (NPCD) is the source of the primary outpatient ICD-9 diagnosis code(s) that identify the primary reason the patient presented for treatment. The Metastatic Class is funded in Price Group # 6, which is higher than the Multiple Problem classes. Patients with a primary outpatient diagnosis of Metastatic Cancer are placed in this class when the care received was predominant or had a minimum weight of 3.5 Work Relative Value Unit (RVU). Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: This class was modified to require 3.5 Work Relative Value Units (RVUs). This represents a reduction from the 7 RVUs required in prior years. This class was modified for VERA 2010 to allow a secondary diagnosis of Metastatic Cancer when the patient also receives treatment for cancer as a principal diagnosis during the same year. Care Group and Price Group: Basic Vested Care; Price Group #6 - Significant Diagnoses. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Multiple Medical XE "Multiple Medical" (Class # 26 in the Patient Classification hierarchy)Patient Class Overview:The Multiple Medical patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher on the classification hierarchy and whose inpatient and/or significant outpatient care is for treatment of diseases in more than one Major Diagnostic Category (MDC). MDCs are described in the introduction of this handbook, and include a group of similar diagnostic related groups, such as those affecting a given organ system of the body. Beginning with VERA 2010, this class will include patients that have received inpatient care, outpatient care or a combination of both inpatient and outpatient care when the outpatient services are considered “significant.” Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. Multiple Medical patient class includes patients with either inpatient admission(s) and/or significant outpatient workload in more than one Major Diagnostic Category (MDC). See introduction section of this handbook for information on MDCs. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. Each principal diagnosis code is correlated to one of 25 mutually exclusively major diagnostic categories (MDCs), which are used to determine the precise patient class. (See Appendix B for the ICD-9 to MDC relationship.) Outpatient:The National Patient Care Database (NPCD) is the source of the primary outpatient ICD-9 diagnosis codes, which map to MDCs. (See Appendix B.) Outpatient workload qualifies for the Multiple Medical patient class when it is considered significant. Significant care is defined as at least 7 Work Relative Value Units (RVUs) associated with each outpatient primary diagnosis code, which are ultimately organized by Major Diagnostic Category. The Work RVUs represent the cumulative work values associated with CPT an HCPCS level II codes. Note: Inpatients or outpatients with dual principal diagnoses that include Acute Mental Disease and/or Addictive Disorders are not included in the Multiple Medical patient class. Instead, these patients typically are placed in the Medical + Psych or Substance Abuse patient class. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: No changes for VERA 2013. Care Group and Price Group: Basic Vested Care, Price Group #5 - Multiple Problem. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual.Multiple Sclerosis XE "Multiple Sclerosis" (Class #20 in the Patient Classification hierarchy)Patient Class Overview:The Multiple Sclerosis patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for multiple sclerosis. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis or secondary diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. A patient with the ICD-9 diagnosis code 340.xx as either a principal or secondary diagnosis code in a Patient Treatment File (PTF) N501 section or National Patient Care Database (NPCD) qualifies for this class. The presence of the MS diagnosis code in the PTF or NPCD as noted above ensures that the patient will fall no lower on the classification hierarchy than the Multiple Sclerosis class. Note that MS patients receiving certain pharmaceuticals documented in the Pharmacy Benefits Management (PBM) database will qualify for the MS with Pharmaceuticals patient class, which is higher on the patient classification hierarchy. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A PTF documenting ICD-9 diagnosis code 340.xx as a principal diagnosis or one of the four secondary diagnoses in the PTF N501 segment will qualify for this class. A patient that qualifies for the MS class (either by inpatient or outpatient care) who also has a principal inpatient diagnoses in more than one MDC is classified into the most appropriate combination class that is higher on the classification hierarchy Multiple Medical, Medical + Psych or Substance Abuse, Psych+Substance Abuse). Outpatient:The National Patient Care Database (NPCD) is also a source of the primary and nine secondary outpatient ICD-9 diagnosis codes that qualify for this class. Patients with a primary or secondary outpatient diagnosis code of Multiple Sclerosis 340.xx qualify for this class and will not fall into a class that is lower on the classification hierarchy even when the patient receives inpatient care for reasons other than multiple sclerosis. Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload. Non-VA or Contracted Care: Non-VA outpatient care is not eligible for this patient class. The Fee Payment Files are the inpatient data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Note: Secondary diagnosis codes are not always evident in the Fee Payment files, so a Non-VA PTF would be essential in such circumstances. Classification Criteria Changes for VERA 2013: No changes to class criterion. Care Group and Price Group: Basic Vested Care; Price Group #4 – Oncology/Inf. Diseases/Legally Blind/MS Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual.Multiple Sclerosis with Pharmaceuticals XE "Multiple Sclerosis with Pharmaceuticals" (Class #23 in the Patient Classification hierarchy)Patient Class Overview:The Multiple Sclerosis patient class is based on diagnosis criteria and documentation of specific pharmaceuticals in the Pharmacy Benefits Management (PBM) database during the fiscal year. This class includes patients who received treatment and specific drugs for the inpatient or outpatient treatment of multiple sclerosis and were not included in a patient class higher in the classification hierarchy. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis or secondary diagnosis as well as certain drugs for the treatment of Multiple Sclerosis (MS.) The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. A patient with the ICD-9 diagnosis code 340.xx as either a principal or secondary diagnosis code in a Patient Treatment File (PTF) N501 section OR in the National Patient Care Database (NPCD) qualifies for this class when the patient receives specific High Cost drugs. The Pharmacy Benefits Management (PBM) database is screened to determine whether the patient received at least a two month supply of specific high-cost outpatient drugs for the treatment of MS. The qualifying drugs include: Multiple Sclerosis Pharmaceutical Agents???Glatiramer (Copaxone)?Daclizumab (Zenapax)*? Interferon Beta-1a (Avonex, Rebif)?Dalfampridine(Ampyra)*?Interferon Beta-1b (Betaseron or Extavia*)?Fingolimod (Gilenya)*?Natalizumab (Tysabri) ?Mitoxontrone (Novantrone)?Alemtuzumab (Campath)*?Rituximab (Rituxan)*????* Indicates effective in FY2012??Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A PTF documenting ICD-9 diagnosis code 340.xx as a principal diagnosis or one of the four secondary diagnoses in the PTF N501 segment will qualify for the MS class. MS patients receiving certain pharmaceuticals for the treatment of MS will qualify for the MS with Pharmaceuticals patient class, which is higher on the patient classification hierarchy. Outpatient: Patients with a primary or secondary outpatient diagnosis code of Multiple Sclerosis 340.xx will qualify for this class, even if the patient has inpatient care for reasons other than multiple sclerosis. The National Patient Care Database (NPCD) is the source of the primary and nine secondary outpatient ICD-9 diagnosis codes. The PBM is the data source for the two month supply of qualifying MS drugs. Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: Non-VA outpatient care is not eligible for this class. The PBM is the data source for the two month supply of MS drugs noted in paragraph “B” above. The Fee Payment Files are the inpatient data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. The diagnosis code for MS is frequently listed as a secondary diagnosis code. Classification Criteria Changes for VERA 2013: The PBM file has been updated to include the drugs delivered by IV as part of an outpatient encounter beginning in FY 2010 and newly approved pharmaceutical agents. Care Group and Price Group: Basic Vested Care; Price Group #5 – Multiple Problem Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Musculoskeletal Disorders XE "Musculoskeletal Disorders" (Class # 8 in the Patient Classification hierarchy)Patient Class Overview:The Musculoskeletal Disorders patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for treatment of musculoskeletal disorders. B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. The Musculoskeletal Disorders patient class includes principal ICD-9 diagnosis codes in the following DRGs: MDC 8: Diseases and Disorders of the Musculoskeletal System(DRGs 453-517, 533-566 )Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG). DRGs are aggregated to one of 25 mutually exclusively major diagnostic categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) Outpatient: The National Patient Care Database (NPCD) is the source of the primary outpatient ICD-9 diagnosis code(s) that identify the primary reason the patient presented for treatment. The Work Relative Value Unit (RVU) for clinical codes including CPT codes and HCPCS II codes is used to determine predominant outpatient diagnosis. If a patient receives outpatient services in more than one MDC, the predominant MDC is used in the classification process. The predominant diagnosis is determined by the cumulative sum of Work RVUs by diagnosis and is used for outpatient classification. These diagnosis codes also correlate to a specific MDC. (See Appendix B.) Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to this class. Care Group and Price Group: Basic Vested Care, Price Group #2 - Basic Medical/Heart, Lung, Gastrointestinal. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Oncology XE "Oncology" (Class # 18 in the Patient Classification hierarchy)Patient Class Overview:The Oncology patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for oncology treatment. Note that certain diagnoses codes for a malignant neoplasm qualify for the Metastatic Cancer patient class, which is higher on the classification hierarchy. Precise diagnosis codes for the Metastatic Cancer patient class are noted in D. below. Data Sources(s) and Class Criteria:The Oncology patient class includes patients with any of the following principal diagnosis codes:ICD-9 diagnosis code for a malignant neoplasm (the range includes ICD-9 140 to 208.XX excluding codes 196.X to 198.XX as indicated in D. below.) Note: The “X” variable in the diagnosis code allows any number in its place. These ICD-9 diagnosis codes are aggregated to many different MS-DRGs. Below is the precise list of MS-DRGs these diagnosis codes map to, organized by MDC. * Note that MDC 17 includes principal diagnosis codes for V58.0 Radiotherapy, V58.11 Antineoplastic Chemotherapy and V58.12 Antineoplastic ImmunotherapyInpatient:The Patient Treatment File (PTF) N501 episode segments are the source of inpatient data for the Oncology patient class. Unlike most of the Basic Vested classes, the Oncology class is not defined by a single MDC because numerous body systems can be affected. Instead, specific ICD-9 codes as well as DRGs are used as the principal classification criteria. Outpatient: The National Patient Care Database (NPCD) is the source of the primary outpatient ICD-9 diagnosis code(s) that identify the primary reason the patient presented for treatment. The Work Relative Value Unit (RVU) for clinical codes including CPT codes and HCPCS II codes are used to determine predominant outpatient diagnosis. If a patient receives outpatient services in more than one MDC, the predominant MDC is used in the classification process. The predominant diagnosis is determined by the cumulative sum of Work RVUs by diagnosis and is used for outpatient classification. Note that in some situations, the predominant MDC may be in a VERA Patient Class that is lower on the classification hierarchy than the Oncology patient class. These diagnosis codes also correlate to a specific MDC. (See Appendix B.) Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload.Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: No change. However, beginning with VERA 2010, patients with a primary diagnosis code for cancer accompanied by a secondary diagnosis code of metastatic cancer will be placed in the Basic Care Metastatic Cancer patient class, which is higher on the Patient Classification Hierarchy. Qualifying codes include :196.X to 196.X - Secondary and unspecified Malignant neoplasm of lymph nodes197.X to 197.X - Secondary malignant neoplasm of respiratory and digestive systems198.X to 198.XX - Secondary malignant neoplasm of other specified sites Care Group and Price Group: Basic Vested Care, Price Group #4 -Oncology/Infectious Disease/Legally Blind. Eligibility for VERA funding: The VERA 10 prices were computed for Enrollment Priority Groups (PG) 1-6 and PG 7 & 8. With the exception of non-veterans in the C&P patient class, Basic Care non-veterans are not VERA-funded Classification Timeframe: Annual. Other Acute Diseases XE "Other Acute Diseases" (Class # 5 in the Patient Classification hierarchy)Patient Class Overview:The Other Acute Diseases patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for treatment of acute diseases listed in the MDCs below. Data Sources(s) and Class Criteria: This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. The Other Acute Diseases patient class includes patients with principal ICD-9 diagnosis codes in the following DRGs: MDC 9:Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast; (All DRGs in MDC 9)MDC 16: Diseases and Disorders of the Blood and Blood Forming Organs and Immunological DisordersDRGs: 799-804, 808-816 (All DRGs in MDC 16)MDC 18: Infectious and Parasitic Diseases; DRGs: 853-858, 862-872 (All DRGs in MDC 18)MDC 21: Injury, Poisonings and Toxic Effects of Drugs; DRGs: 901-909, 913-923 (All DRGs in MDC 21)MDC 22: Burns; DRGs: 927-929, 933-935 (All DRGs in MDC 22)MDC 23: Factors Influencing Health Status, DRG 939-941, 945-951 (Most DRGs in MDC 23)MDC 24: Multiple Significant Trauma, DRGs: 955-959, 963-965 Pre-MDC: (No Title) DRGs: 1-13, 981-989, 998-999Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG). DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.)Outpatient:The National Patient Care Database (NPCD) is the source of the primary ICD-9 diagnosis codes that qualify for this class. The Work Relative Value Unit (RVU) for clinical codes including CPT codes and HCPCS II codes are used to determine predominant outpatient diagnosis. If a patient receives outpatient services in more than one MDC, the predominant MDC is used in the classification process. The predominant diagnosis is determined by the cumulative sum of Work RVUs by diagnosis and is used for outpatient classification. These diagnosis codes also correlate to a specific MDC. (See Appendix B.) Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include the Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to this class. Care Group and Price Group: Basic Vested Care, Price Group # 2 - Basic Medical/Heart, Lung and Gastrointestinal. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Psych+Substance Abuse XE "Psych+Substance Abuse" (Class # 24 in the Patient Classification hierarchy)Patient Class Overview:The Psych+Substance Abuse patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy. This class includes patients with diagnoses for mental illness and addictive disorders. Furthermore, a patient can qualify for this class with a single admission and the appropriate diagnosis codes.B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. An inpatient with a principal or secondary diagnosis in MDC 19 and MDC 20 will qualify for the Psych+Substance Abuse patient class.MDC 19: Mental Diseases and Disorders (DRGs 876-887) (Excluding inpatient care for PTSD-Acute patient class includes patients with a principal ICD-9 diagnosis of 309.8X series. PTSD –Acute class is higher on the classification hierarchy.)MDC 20: Alcohol/Drug use and Alcohol/Drug Induced Mental Disorders (DRGs 894-897)Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG.) DRGs are aggregated to one of 25 mutually exclusive Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) The DRGs for this patient class are listed below. Outpatient:The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 primary diagnosis codes, which map to MDCs. Outpatients qualify for the Psych+Substance Abuse patient class with a specified level of treatment in the ICD-9 diagnosis codes associated with both MDC 19 and MDC 20. The level of treatment is determined by the cumulative weight of the CPT code’s Resource-Based Relative Value Units (RVUs) for each diagnosis code. A patient is placed in the Psych+Substance Abuse class with a combined weight of 14 RVUs in MDC 19 and MDC 20 where one of the MDC has a minimum of 3.5 RVUs. In addition, if this patient has 7 or more RVUs in a medical MDC, they would move to the Medical + Psych or Substance Abuse patient class. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: No changes to this class. Care Group and Price Group: Basic Vested Care, Price Group #5 - Multiple Problem. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. PTSD – Acute XE "PTSD – Acute" (Class # 28 in the Patient Classification hierarchy)Patient Class Overview:The PTSD - Acute patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient care is for a principal diagnosis of post-traumatic stress disorder treatment. Note that patients receiving outpatient care for PTSD are not included in this patient class (see D. below). Data Sources(s) and Class Criteria:Inpatient: This Basic Vested patient class uses the patient's principal inpatient diagnosis as the source of classification criteria. A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. Each principal diagnosis code is correlated to one of 25 mutually exclusively major diagnostic categories (MDCs), which are used to determine the precise patient class. (See Appendix B for the ICD-9 to MDC relationship.) The Diagnostic Related Group (DRG) is also listed below and includes factors in addition to the MDC, such as secondary diagnoses and clinical procedures. PTSD-Acute patient class includes patients with a principal ICD-9 diagnosis of 309.8X series. Note: The “X” variable in the diagnosis code allows any number in its place. Note that patients with a PTSD diagnosis are retained in the PTSD-Acute class and are not included in the Psych+Substance Abuse (MDC 19 and 20) patient class. The PTSD-Acute patient class is higher on the classification hierarchy than the multiple diagnoses patient classes.Outpatient: Patients receiving exclusively outpatient care for PTSD are not included in this class. The National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis codes. Outpatient diagnosis codes also correlate to a specific MDC. (See Appendix B.) Outpatient care for a diagnosis of PTSD (309.8) will be placed in the Acute Mental Diseases patient class. If a patient receiving outpatient care qualifies for more than one MDC, the predominant MDC is used unless the patient qualifies for a combination class. The process for determining the predominant MDC is identified in the Basic Vested Classification Criteria section on page 10. Patients with significant outpatient care for PTSD as well as other conditions may qualify for classes in the Multiple Problem price group. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: There were no changes made to the class criteria. This class is exclusively for patients receiving inpatient care for the treatment of PTSD. Care Group and Price Group: Basic Vested Care, Price Group #5 - Multiple Problem. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Pulmonary Disease XE "Pulmonary Disease" (Class # 12 in the Patient Classification hierarchy)Patient Class Overview:The Pulmonary Disease patient class is based on diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient or outpatient care is for treatment of Diseases and Disorders of the Respiratory System. Note that certain pulmonary diagnosis codes may qualify for the High Cost Pneumonia patient class. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal diagnosis. The classification process assesses all inpatient care and outpatient care during the fiscal year and places the patient in the highest class the patient qualifies for based on all care received during the fiscal year. Inpatient and Outpatient care are assessed separately and all services are considered in the classification process. The Pulmonary Disease patient class includes patients with a principal ICD-9 diagnosis in: MDC 4: Diseases and Disorders of the Respiratory SystemDRGs: 163-168, 175-208Note: Certain diagnosis codes in MDC 4 qualify for the High Cost Pneumonia patient class, which is higher on the classification hierarchy. See High Cost Pneumonia patient class criteria for complete list. Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal diagnosis is documented in the PTF N501 episode segment using ICD-9 codes. The patient class is determined when principal diagnosis code(s) are mapped to a Diagnostic Related Group (DRG). DRGs are aggregated to one of 25 mutually exclusively Major Diagnostic Categories (MDCs). (See Appendix B for the ICD-9 to MDC relationship.) Outpatient:The National Patient Care Database (NPCD) is the source of the primary ICD-9 diagnosis codes that qualify for this class. The Work Relative Value Unit (RVU) for clinical codes including CPT codes and HCPCS II codes are used to determine predominant outpatient diagnosis. If a patient receives outpatient services in more than one MDC, the predominant MDC is used in the classification process. The predominant diagnosis is determined by the cumulative sum of Work RVUs by diagnosis and is used for outpatient classification. These diagnosis codes also correlate to a specific MDC. (See Appendix B.) Note that a patient receiving significant levels of workload in more than one MDC may qualify for a combination class in the Multiple Problem price group (5). These classes include Multiple Medical, Medical + Psych or Substance Abuse, and Psych+Substance Abuse classes which recognize significant levels of care in more than one MDC. This care may include either an inpatient admission or significant levels of outpatient care in more than one MDC during the fiscal year. Significant outpatient workload is defined as a cumulative total of at least 7 Work RVUs of outpatient workload in an MDC. See the Basic Vested Classification Criteria beginning on page 10 for a detailed explanation on determining the predominant MDC and identifying significant outpatient workload. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Classification Criteria Changes for VERA 2013: While no changes were made to this class criterion, note that some of the certain inpatient diagnosis codes previously associated with this class in MDC 4 map to the High Cost Pneumonia patient class, which is higher on the classification hierarchy. Care Group and Price Group: Basic Vested Care group, Heart, Lung, Gastrointestinal Price Group #2. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: AnnualRespiratory Failure XE "Respiratory Failure" (Class # 31 in the Patient Classification hierarchy)Patient Class Overview:The Respiratory Failure patient class is based on principal or secondary inpatient diagnosis criteria. This class includes patients who were not included in a patient class higher in the classification hierarchy and whose inpatient care is for treatment of specific conditions indicating respiratory failure or respiratory arrest identified by ICD-9 diagnosis code below. Outpatient care for the same diagnosis codes is included in this class when the outpatient encounter culminates in an inpatient admission on the same day of care. B. Data Sources(s) and Class Criteria:This Basic Vested patient class is based on the patient's principal or secondary inpatient diagnosis. The classification process assesses all inpatient care and outpatient care that resulted in an inpatient admission on the same day of care. Unlike the majority of VERA patient classes that are defined by one of 25 mutually exclusively major diagnostic categories (MDCs), the Respiratory Failure patient class is based exclusively on a principal or secondary inpatient diagnosis code unless noted below: ICD-9 CodeDescription 799.1Respiratory arrest518.84Acute and chronic respiratory failureV55.0XAttention to Tracheostomy (Principal or secondary diagnosis code)V44.0XTracheostomy status (typically a secondary diagnosis code.) V46.1XOther dependence on machines, respirator status (typically a secondary diagnosis code.)Inpatient: A Patient Treatment File (PTF) is generated for every inpatient hospitalization and bed transfer. A patient's principal and secondary diagnosis codes are documented in the PTF N501 episode segment using ICD-9 codes. Any of the Respiratory Failure diagnosis codes above documented as either a principal or secondary diagnosis code would qualify for this patient class. Outpatient: Outpatient encounters for Respiratory Failure diagnosis codes that do not result in an inpatient admission do not qualify for this class. The National Patient Care Database (NPCD) is the source of the primary outpatient ICD-9 diagnosis codes that will qualify for this class only when the outpatient encounter culminates in an inpatient admission on the same day of care. Patients with outpatient encounters for Respiratory Failure diagnosis codes will be screened to determine whether an admission occurred on the same day of care. Note that in such circumstance, the admitting diagnosis should, but does not necessarily include the required Respiratory Failure codes. For this reason, the outpatient encounter date is matched to inpatient admission dates to qualify for this class. This class is intended to capture patients requiring inpatient care for the treatment of Respiratory Failure codes noted above. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes in the 501 segment. Note: Secondary diagnosis codes are not always evident in the Fee Payment files, so a Non-VA PTF would be essential in such circumstances. Classification Criteria Changes for VERA 2013: This class was modified to include secondary inpatient diagnosis codes documented in the N501 segment because coding requirements often require these codes to be listed as secondary when other conditions are evident. In addition, outpatient care for these primary diagnosis codes that does not culminate in an inpatient stay will no longer qualify for this patient class. In prior years, outpatient care alone qualified for this class. Care Group and Price Group: Basic Vested Care; Price Group #6 - Significant Diagnoses. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class Classification Timeframe: Annual. The 27 Complex Care Group Patient ClassesAIDS or HIV+ with Anti Retro-Viral (ARV) Therapy Blind Rehabilitation ServiceCCHT-Non-Institutional Care (NIC)Community Nursing HomeEnd Stage Renal DiseaseHepatitis C with Anti-Viral (AV) TherapyHome-Based Primary Care (HBPC)Homeless-CMILegacy LTC/IntermediateLong Stay Community Living ClassMental Health Intensive Case Management (MHICM)Other PsychosisPolytraumaPTSD – ChronicResidential Rehabilitation Short Stay CLCSkilled Nursing and Rehabilitation Schizophrenia & DementiaSCI Para - New Injury/InstitutionalizedSCI Para – Old InjurySCI Quad – New Injury/InstitutionalizedSCI Quad – Old InjuryShort Stay Community Living ClassStrokeSubstance AbuseTransplantTraumatic Brain Injury & PolytraumaVentilator DependentAIDS or HIV+ with ARV Therapy XE "AIDS or HIV+ with ARV Therapy" (Class #35 in the Patient Classification hierarchy) Patient Class Overview:The Clinical Case Registry: (CCR:HIV) is the ARC’s data source for identifying all HIV patients for the annual patient classification process. The CCR:HIV consists of patients with identified HIV infection who have been entered into the local registry by the facility CCR:HIV coordinator. The CCR:HIV captures service utilization information, including pharmacy prescriptions and laboratory test results. In addition, patients are categorized by disease severity, based on CD4+ cell count, CD4 percentage, and by the presence of an AIDS-defining opportunistic infection. An AIDS-defining opportunistic infection (AIDS OI) is defined by the 1993 AIDS surveillance case listed in 1993 Revised Classification System for HIV Infection and Expanded Surveillance Case Definition for AIDS Among Adolescents and Adults, Appendix B, MMWR, December 18, 1992, Vol. 41/RR-17. The AIDS defining condition is documented by a manual change of the patient’s classification to AIDS OI within the local CCR:HIV. HIV patients are classified as Complex Care group when they meet either of the following criteria:AIDS-defining opportunistic infection clinical condition, ORHIV+ and have received at least one prescription for an ARV during the classification year. Each criterion is listed separately in the Clinical Case Registry:HIV Data Sources(s) and Class Criteria:The Clinical Case Registry: HIV (CCR:HIV) is the ARC's data source for all HIV patients. Each year, the ARC receives data from the National CCR, compiled from the local CCR:HIVs. Patients are entered into the CCR:HIV by the facility's CCH:HIV coordinator based upon the diagnosis of HIV infection through confirmed positive antibody test results or the presence of the ICD-9 diagnosis code 042. Complex Care Definition: Clinical AIDS by an opportunistic infection (AIDS OI) is documented by entry in the local CCR:HIV. Once a patient receives an AIDS OI diagnosis, the patient is considered permanent in this class. Antiretroviral therapy use is also documented in the National CCR and can be confirmed by Pharmacy Benefits Management (PBM) data. HIV patients receiving ARVs during the classification year will be classified as "HIV with ARV" and included in the Complex Care pricing group on an annual basis only. As of September 2012, the list of ARV agents includes the following: *This list is updated regularly by the Center for Quality Management in Public Health as new agents are approved for the treatment of HIV infection by the Food and Drug Administration.GenericName BrandNational Drug File Internal Record NumberAbacavirZiagen3535Abacavir/LamivudineEpzicom3994Abacavir/Lamivudine/ZidovudineTrizivir3677AmprenavirAgenerase3568AtazanavirReyataz3890Cobicistat/Elivitegravir/Emtricitabine/TenofovirStribild4753DarunavirPrezista4140DelavirdineRescriptor3395DidanosineVidex2576EfavirenzSustiva3528Efavirenz/Emtricitabine/TenofovirAtripla4188EmtricitabineEmtriva3888Emtricitabine/TenofovirTruvada3990EnfuvirtideFuzeon3864EtravirineIntelence4335FosamprenavirLexiva3918IndinavirCrixivan3350LamivudineEpivir3315Lamivudine/ZidovudineCombivir3465Lopinavir/RitonarvirKaletra3660MaravirocSelzentry4297NelfinavirViracept3394NevirapineViramune3377RaltegravirIsentress4305RilpivirineEdurant4638Riplivirine/tenofovir/emtricitabineComplera4667RitonavirNorvir3349SaquinavirFortovase, Invirase3316StavudineZerit3225TenofovirVired3724TipranavirAptivus4059ZalcitabineHivid2270ZidovudineRetrovir2147Non-VA or Contract Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Criteria changes to the AIDS or HIV+ with ARV Therapy patient class: The ARV drug therapy list is modified on an ongoing basis, and new drugs added during a fiscal year. Check with the ARC website FAQ section and/or the ICR for most recent ARV agents. Care Group and Price Group: Complex Care; Price Group #7 - Specialized Care Price group. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are funded in VERA. Classification Timeframe:AIDS by Clinical Condition is a permanent class.HIV+ on ARV Therapy is an annual class. Patients are placed in the “HIV+ with ARV Therapy” Complex Class when fiscal year documentation supports that the patient is receiving ARV drug therapy during the classification year. Blind Rehabilitation Service XE "Blind Rehabilitation Service" (Class # 41 in the Patient Classification hierarchy)Patient Class Overview:The Blind Rehabilitation Service Class is based on utilization criteria that equates to three bed days of care (BDOC) in a Blind Rehabilitation Service. A Blind Rehabilitation Services is identified in the Patient Treatment File (PTF) as Treating Specialty/Physical Location "21." A patient must meet the Blind Rehabilitation patient class criteria each year to remain in this class. B. Data Source and Explanation: The PTF is the only data source for the Blind Rehabilitation Service patient class. Specifically, the PTF Discharge Diagnostic Transaction (N501) is reviewed for code "21" indicating treatment in a Blind Rehabilitation service. It should be noted that the required three BDOC do not need to be consecutive days attained during a single admission, but must occur within the span of a fiscal year. Non-VA or Contracted Care: The Blind Rehabilitation patient class is exclusively for patients treated in a VHA Blind Rehabilitation Service center. Blind Rehabilitation Centers (BRC) are located at the following:Central BRC Hines, IllinoisWestern BRC Palo Alto, CAEastern BRC West Haven, CTAmerican Lake BRC American Lake, WAWaco BRC Waco, TXSoutheastern BRC Birmingham, ALPuerto Rico BRC San Juan, PR Southwestern BRC Tucson, AZAugusta BRC Augusta, GAWest Palm Beach BRC West Palm Beach, FLBiloxi, MS Cleveland, OH Long Beach, CA (opening in FY12).Criteria Changes to the Blind Rehabilitation patient class for VERA 2013:No changes for the VERA 2013 process. There was a change to the BR classification criteria for the VERA 2012 Model that increased the required BDOC in the fiscal year to a minimum of three BDOC from a single BDOC. The increase in BDOC ensures that this patient class identifies patients that have received a minimum level of services in a Blind Rehabilitation unit. Care Group and Price Group: Complex Care; Price Group #8 - Supportive Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: Annual. A patient must meet the Blind Rehabilitation class criteria each year to remain in the class.Care Coordination Home Telehealth – Non-Institutional Care XE "Care Coordination Home Telehealth –Non-Institutional Care" (Class #38 in the Patient Classification hierarchy)Patient Class Overview:The Care Coordination Home Telehealth (CCHT) – Non-Institutional Care (NIC) patient class is based on a CCHT?Continuum of Care assessment performed by a CCHT care coordinator and a minimum?of?three months of CCHT care of the patient during the fiscal year.? ??This was a new class for the VERA 2011 Model supported by the Office of Telehealth Services (OTS), which has noted a significant reduction in bed days of care and hospital admissions amongst Veteran patients managed in CCHT programs.? Data Sources(s) and Class Criteria:This Complex Care class is based on two factors including a CCHT Continuum of Care assessment which places a patient into the Non-Institutional Care (NIC) category of care and a minimum of three months of CCHT care (documented using the Home Telehealth Non-Video monitoring DSS stop code 683) during the fiscal year while the patient is enrolled in the CCHT program.? The designation of patients into the NIC category of care is entered by a CCHT Care Coordinator into the CCHT vendor databases, which is maintained in the CCHT Vendor cube on the VSSC website. ?CCHT Assessment:? The CCHT assessment tool, otherwise known as the Continuum of Care Form (CCF), is located in CPRS and must be completed by a CCHT care coordinator. The assessment may occur while the patient is in an inpatient status, but more often occurs during an outpatient encounter.? The results of this assessment are documented in CPRS and are subsequently entered into the CCHT vendor data base and transmitted to the VSSC.? Patients with a category of care of “Non-Institutional Care (NIC)”?are candidates for this class if they meet the annual workload requirements in “2” below.??? In addition to designation of the NIC Category of Care, outpatient workload encounters documented in the National Patient Care Database (NPCD) must include at least three separate months of CCHT care (using the DSS Primary stop code described below).? Although the monthly encounters are not required to occur in immediate successive months, they must be attained during the fiscal year while the patient is in an “Enrolled” status. Encounters documented in days after the date the patient has been dis-enrolled from the CCHT program will not count towards the required three encounters.?? DSS CS 683:? Home Telehealth Non-Video Monitoring(Primary clinic stop)Records workload by VA health care professionals using non-video electronic in-home messaging devices for the remote monitoring of patients on a regular basis.? This code is reported once each calendar month per patient enrolled in CCHT that uses a messaging device. Not to be used to document workload for patients using other technology devices that does not have in-home messaging functionality.? For use by approved Care Coordination Home Telehealth (CCHT) Programs only.? ???????????????? Non-VA or Contracted Care:? There is no non-VA source for this patient class.? All CCHT assessments must be completed by CCHT care coordinators within the VHA and the designation of the NIC category of care must be evident in the national database supported by the VSSC. ??Classification Criteria Changes for VERA 2013: None. This was a new class for VERA 2011.? Note that there is a Basic Vested class for CCHT patients with a Chronic Care Management (CCM) category of care. Also, beginning in FY12, DSS CS 683 formerly known as CCHT Non-Video Monitoring is renamed to Home Telehealth Non-Video Monitoring. Care Group and Price Group: Complex Care; Price Group #7, Specialized Care.? Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients; Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. Basic Care non-veterans are not VERA-funded with the exception of non-veterans in the C&P patient class. Classification Timeframe: Annual. Community Nursing Home XE "Community Nursing Home" (Class # 43 in the Patient Classification hierarchy)Patient Class Overview: The Community Nursing Home (CNH) patient class is based on utilization criteria, which is determined by the VA-paid Bed Days of Care (BDOC) in a contracted nursing home. It is important to note that the required amount of BDOC is different depending upon the data source used to document the contracted care (see below). Patients are placed in the CNH patient class if they have not received care in a VA intermediate or VA Community Living Center bed; but have a specified amount of BDOC in a contracted community nursing home. Furthermore, because RUG scores are not available for CNH patients, they are not used as a classification factor for this patient class. Data Sources(s) and Class Criteria: There are three separate data sources used for the Community Nursing Home patient class:A census Patient Treatment File (PTF);A discharge Patient Treatment File (PTF) indicating Community Nursing Home (CNH), which may be indicated as Facility Type 42; and/or The Inpatient Contract Payment Fee File that contains community nursing home payments identified by the following purpose of visit (POV) fields: 40: Community Nursing Home for Service Connected Disabilities41: Community Nursing Home for Non-Service Connected Disabilities43: Community Nursing Home hospice and Palliative care 44: Community Nursing Home Respite care Patients are placed in the Community Nursing Home (CNH) patient class according to the following criteria:1. With a PTF. When a PTF (census or discharge) is completed for CNH care, a patient must have at least 31 BDOC in a Community Nursing Home documented as Facility Type 42 — Community Nursing Home.OR 2. In the absence of a PTF, the BDOC are computed using the Contract Payment Fee File. When the Fee file is used to document BDOC, a patient must have a minimum of 41 BDOC in the fiscal year. The BDOC are computed using the Fee file fields "payment start date" and the "payment end date."Non-VA or Contracted Care: The CNH patient class is for patients receiving VA paid care in a contracted or non-VA nursing home. Data sources noted above are used to document this care, however, note that a minimum of 41 BDOC are required when a PTF is not completed. It is recommended that a PTF be used to document all VA purchased nursing home care services. Contracted CNH care that is not documented in the census PTF, PTF or paid for using the Fee Payment system is not accounted for in the patient classification process.Criteria Changes to the Community Nursing Home patient class criteria for VERA 2013: There were no changes made to the CNH patient class criteria. The last change occurred in fy2005 when quarterly censuses PTFs were mandated for patients residing in CNHs. Care Group and Price Group: Complex Care; Price Group #8, Supportive Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are funded in VERA. Classification Timeframe: Annual. Patients in the CNH class must meet the required BDOC each year. End Stage Renal Disease (ESRD) XE "End Stage Renal Disease (ESRD)" (Class #54 in the Patient Classification hierarchy)Patient Class Overview:The End Stage Renal Disease (ESRD) patient class is based on procedure coding for inpatient and outpatient ESRD treatments. Each ESRD code is assigned a weighted work value in the chart below. Patients that receive significant chronic dialysis treatment (as determined by the total weighted work value of all ESRD treatments) are placed in this class. Treatments are weighted according to the location of treatment including inpatient, outpatient, contracted care or home treatments. Data Sources(s) and Class Criteria:The four data sources used to identify patients who qualify for the ESRD patient class are the Patient Treatment File (PTF) N601 transactions, National Patient Care Database (NPCD), the Inpatient Encounter files, the Home Dialysis Reporting System (reported by to the Allocation Resource Center through the ARC website), and the Fee Payment Files.VA clinicians defined “significant chronic dialysis treatment” as 30 Dialysis Weighted Work Units (WWUs). These weights (shown below) reflect the relative cost for each type of dialysis treatment. For example, dialysis procedures provided in Intensive Care Units (Medical ICU and Surgical ICU) are more resource-intensive than other (non-ICU) inpatient or outpatient dialysis treatment and are weighted accordingly. Data Source Data Element WeightPatient Treatment File (PTF)ICD-9 Codes 39.95 & 54.98MICU & SICU ONLY6.0Patient Treatment File (PTF)ICD-9 Codes 39.95 & 54.98NOT MICU & NOT SICU2.5National Patient Care Database (NPCD)Clinic Stops 602 – 6082.5Home Dialysis Reporting System (reported directly to ARC web-based system)Treatment Types: CAPD, CCPD, IDP, HHDT1.4Contract Dialysis90935, 90937, 90945, 90947 & 90999 2.4Continuous ambulatory peritoneal dialysis (CAPD) *Continuous cycling peritoneal dialysis (CCPD)Intermittent peritoneal dialysis (IPD) * Home Hemodialysis Treatment (HHDT)Non-VA or Contracted Care: The Fee Payment File is the data source for contracted on non-VA ESRD. To ensure that appropriate WWUs are credited, ESRD treatments should be itemized by CPT code in the Fee Payment Files. Failure to itemize ESRD treatments may result in under reported workload. Non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which captures ICD-9 procedure codes for inpatient dialysis treatments. Beginning in FY 2010, this class will also include dialysis purchased as part of the CBO Non-VA Dialysis Pilot Project whereby the providers submit electronic claims directly to VA Austin Financial Service Center (FSC). Criteria Changes to the ESRD patient class for VERA 2013: No changes. Care Group and Price Group: Complex Care; Price Group #10, Critically Ill. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are funded in VERA. Classification Timeframe: Annual. A patient must meet the ESRD classification criteria each year. Hepatitis C with Anti-Viral Therapy XE "Hepatitis C with Anti-Viral Therapy" (Class # 34 in the Patient Classification hierarchy)Patient Class Overview:The Hepatitis C with Anti-Viral (AV) Therapy patient class includes patients identified in the Clinical Case Registry (CCR) as Hepatitis C positive who are prescribed specific anti-viral therapy for Hepatitis C. Classification in the Complex Care Hep. C with Anti-Viral therapy class is limited to one year in the lifetime of a patient, even if the patient remains on the AV therapy. Data Sources(s)/Class Criteria: Beginning with the VERA 2012 Model, the Clinical Case Registry (CCR) is the VA’s official data source for patients with Hepatitis C (see VHA DIRECTIVE 2011-026) and the drugs they receive. The CCR documents patients that have received either inpatient or outpatient care as follows: The Patient Treatment File (PTF) N501 episode segments are the source of inpatient identification. Patients qualify for this class with a principal ICD-9 diagnosis listed below, or a secondary diagnosis from the list when the principal diagnosis is from MDC 7: Diseases and Disorders from the Hepatobiliary System and Pancreas (DRGs 405-416, 420-446) : ICD-9 Diagnosis: 070.41 Acute hepatitis C with hepatic coma070.44 Chronic hepatitis C with hepatic coma070.51 Acute hepatitis C without mention of hepatic coma070.54 Chronic hepatitis C without mention of hepatic coma070.70 Unspecified viral hepatitis C without hepatic coma070.71 Unspecified viral hepatitis C with hepatic comaV02.62 Hepatitis C carrierThe National Patient Care Database (NPCD) is the source of the outpatient ICD-9 diagnosis. Outpatients are considered Hepatitis C positive by having an outpatient encounter with a primary ICD-9 diagnosis listed above. Note: The required encounters can include telephone encounters. The CCR also indicates whether the patient has received any of the following qualifying AV drugs: * Interferon Alfa, Interferon Alfacon, Rebetron, Peginterferon (also known as Peginterfer), Ribavirin and all investigational and study drugs in VA class IN140 Beginning in May 2011, boceprevir (Victrelis) and telaprevir (Incivek)Note regarding patients enrolled in research studies or clinical trials: Patients that receive medications as part of the clinical trial are not included in the Complex Care Hepatitis C patient class, primarily because the VHA does not pay for the medication(s) for clinical trials.Non-VA or Contracted Care: Non-VA care does not qualify for this patient class. Criteria Changes to the Hep. C patient class for VERA 2013: No changes to the classification criteria, however, updates to the list of the qualifying AV drugs are maintained on the ARC website in the FAQ section. . Care Group and Price Group: Complex Care; Price Group #7, Specialized Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements are TRICARE are funded in VERA. Classification Timeframe: Annual. A patient is eligible for the Hepatitis C+ with AV Therapy patient class once in a lifetime. Home-Based Primary Care (HBPC) XE "Home-Based Primary Care (HBPC)" (Class # 40 in the Patient Classification hierarchy)Patient Class Overview: The Home-Based Primary Care (HBPC) patient class is based on utilization criteria that equates to a minimum of 10 "qualified" days of care in the home setting during the fiscal year. This patient class is intended to include patients that receive a high level of home care services in lieu of institutional long term care services. Data Source(s) and Class Criteria:The data sources used to identify HBPC patient class workload includes the National Patient Care Database (NPCD) for VHA provided care and the Fee Payment Files for contracted/non-VA care. However, note that care provided by means of telemedicine is limited to five of the required qualified visits and is restricted to Real Time Video Care that is documented as a secondary DSS Clinic (Credit) Stop 179. Specifically, the data sources for the 10 visits are as follows: VHA home visits documented in the National Patient Care Database (NPCD) are screened for codes (CPT and HCPCS Level II G-codes) representing health care services. The codes associated with the DSS Clinic Stops below are evaluated for qualified visits.HBPC clinic stops 170 -177, 156 and 157 (beginning FY2009 for HBPC Psychologist and HBPC Psychiatrist, respectively) 118, Home Treatment Services. Non-VA home visits: Workload documented in the Contract Fee Files is reviewed for "qualified visits." Fee File data is identified by the following purpose of visit (POV) codes: 70 - Home Health Nursing Services; 71- Homemaker/Home Health Aide Services; 73 – Respite Care in ADHC; and 74 – Home Health Services (Non-nursing Professional). All Non-VA workload associated with these POVs is assessed for "qualified visits." NOTE: Due to an error in the Fee Payment System, workload in POV 71: Home maker /home health aide services will be screened until the Fee System is corrected. However, services provided by homemaker/home health aides is not considered a qualified visit for the HBPC patient class. The HBPC patient class requires at least 10 qualified home days of care (also referred to as visits) in a fiscal year. It should be noted that days of care/visits are counted by the day, irrespective of whether more than one clinician provides care during a single day. For example, multiple providers in one day would count as a single day of care for the HBPC patient class. Furthermore, of the required 10 qualified visits, five of these visits may be completed by Telehealth Real Time Video Care that is documented as DSS Clinic Stop 179 as a secondary clinic stop.Criteria for a "Qualified Visit" A home visit is considered "qualified" if the Current Procedural Terminology (CPT) code or the Healthcare Common Procedure Coding System (HCPCS) code associated with the visit meets the criteria listed below. CPT codes: A CPT codes with a “Work” Relative Value Unit (RVU) greater than zero represents a qualified visit. The RVU is obtained from the Medicare Resource-Based Relative Value Scale (RBRVS) Fee Schedule, which is published each year by the Centers for Medicare and Medicaid Services (CMS.) Use the following ARC website address to determine the value of specific CPT codes. In addition to visits with an RVU greater than zero, Appendix E of the Patient Classification handbook identifies a list of qualifying HCPCS Level II codes. This list contains codes considered qualified visits that do not have an RVU greater than zero. For example, the following HCPCS G-codes below do not have a “work” RVU but are considered qualified visits.? Note that G-0156 Homemaker/Home Health Aide is NOT considered a qualified visit. ? Code Service G0151Physical Therapist (PT)G0152Occupation Therapist (OT)G0153Speech and Language Pathologist (SLP)G0154Skilled Nurse? (RN, LPN)G0155Social WorkerG0159*PT G0160*OTG0161*SPLG0162* RNG0163*Skilled nurseG0164*Skilled Nurse*Indicates new code beginning FY 2011.?Non-VA or Contracted Care: All Non-VA care must be accurately processed in the Fee Payment Files. For example, CPT and HCPCS codes should be itemized to ensure that they are appropriately assessed for "qualified" status. The Fee Payment Files are screened for contracted home care visits that meet the qualified criteria noted above. Workload is credited in the fiscal year that the payment was processed, which may not be the same year that the care occurred due to billing cycles. Criteria Changes to the HBPC patient class for VERA 2013: No changes to this class for VERA 2013. A major change to the HBPC patient class occurred in VERA 2010 when up to five of the required 10 qualified visits may be done by real time videoconferencing visits noted above. Care and Price Group: Complex Care, Price Group #8, Supportive Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are funded in VERA. Classification Timeframe: Annual. A patient must meet the HBPC classification criteria each fiscal year. Homeless Chronic Mentally Ill (CMI) XE "Homeless Chronic Mentally Ill (CMI) " (Class # 49 in the Patient Classification hierarchy)Patient Class Overview:The Homeless Chronically Mentally Ill (CMI) patient class was a new class for the VERA 2011 Model. The class is intended for patients that are 1) Designated as homeless (defined below) AND 2) Receive a minimum level of mental health services in a fiscal year. A Homeless Registry maintained in the ARC database tracks homeless patients. Furthermore, because of the comprehensive treatment regimen provided to Homeless CMI patients, the patients receiving exclusively outpatient services are not screened for a Vesting CPT code. Data Sources(s) and Initial Classification Criteria: Patients in this class must meet both the homeless criteria and the mental health utilization requirement to qualify for this class in the initial year. Homeless: For VERA 2012, the designation of homeless was based on either of the following: An ICD-9 diagnosis code of V60.0 (Lack of Housing) must be listed at least once since fiscal year 2009. The V60.0 code must be documented as a secondary diagnosis code in the Patient Treatment File (PTF) for inpatient care, but can be listed as a primary or secondary code in the National Patient Care Database (NPCD) for an outpatient encounter. The V60.0 code needs only to appear once during the fiscal year for the patient to be considered homeless. ORTreatment for a major mental health or substance abuse diagnosis during the fiscal year that included care for homelessness. The precise homeless services includes: An inpatient stay of at least one night in: Treating Specialty 28: Homeless CMI (HCMI) CWT/TR or Treating Specialty 37: Homeless Dom. Outpatient care in any of the following DSS Clinic Stops: DSS Clinic Stop 528: Telephone/Homeless Chronically Mentally Ill (HCMI)DSS Clinic Stop 529: Healthcare for Homeless Veterans (HCHV)/HCMIDSS Clinic Stop 590: Community Outreach Homeless. Beginning with FY2009, a patient meeting the definition of homeless noted above will retain the designation for the two immediate subsequent years, with or without additional documentation of codes indicating homelessness. Mental Health Services (Utilization Requirements): The utilization requirements to qualify for this class include either inpatient BDOC with a principal CMI diagnosis or outpatient visits to mental health clinic stops. The requirements are as follows:Inpatient: In addition to the designation of homeless from above, the patient must have at least 15 inpatient (including residential rehabilitation and excluding pass and AVO days) bed days of care (BDOC) with a principal diagnosis of Chronic Mental Illness from the list below.* ICD-9 CodeDescriptionICD-9 CodeDescription290.XXDementias297.XXParanoid States291.XXAlcoholic Psychoses298.XXOther Nonorganic Psychoses292.XXDrug Psychoses303.XXAlcohol Dependence Syndrome294.XXOther Organic Psychotic Conditions (Chronic)304.XXDrug Dependence295.XXSchizophrenic Disorder305.XXNondependent abuse of Drugs296.XXAffective Psychoses309.8XAdjustment Reaction (PTSD)310.XXSpecific Non-psychotic Mental Disorders due to Brain Damage*Note mental health diagnosis codes must be listed as a secondary diagnosis code when the patient has a principal diagnosis of Alzheimer’s disease (ICD-9 code 331.0X). Outpatient: Since fiscal year 2010, homeless patients with a minimum of 41 outpatient visits (days of care) to any of the CMI DSS Mental Health Clinic Stops designated as “Individual” will qualify for this class. The precise list of Individual CMI clinic stops are identified in item H. Note that while these clinic stops are considered outpatient care, the Inpatient Encounter file is used as a data source to document mental health care provided to VHA inpatients (including patients in residential care). These visits can be performed by telehealth, which is documented in the secondary DSS Clinic Stop. Subsequent Classification Years Although the CMI Retention criteria is intended to be met each year, Homeless CMI patients that do not meet the retention requirements in the immediate subsequent year will not qualify for this class.? If they meet the retention requirements in the second year following classification, they will be placed back in the Homeless CMI class.? CMI Annual Retention CriteriaThe CMI Annual Retention Criteria identifies a series of annual treatment regimens that when met will retain the patient in the Homeless CMI class. The Homeless CMI patients must meet the annual requirements either the immediate subsequent year or the second fiscal year following classification. The treatment regimens include: At least 7 inpatient BDOC (pass and ABO days excluded) with a principal psychiatric diagnosis. The required principal diagnoses include all diagnoses in the MS Diagnostic Related Groups MS-DRGs 876, 880-887, 894-897. Inpatient care can occur in a VHA or non-VA setting provided a PTF is completed for the admission, orVHA outpatient care that equates to at least 6 VHA individual outpatient visits*, orat least 11 VHA group outpatient visits.**Note that the outpatient workload includes data from the Inpatient Encounter file and can be performed by certain Telehealth procedures when they are appropriately documented in the NPCD. There are no restrictions on the number of visits that can be performed by the Telehealth visits documented below. The outpatient care visits are identified by specific Clinic Stops, which are listed in Appendix D. Outpatient care must be provided by a VHA source, as outpatient non-VA care is not considered part of the CMI Retention Criteria. Beginning in FY2008, these outpatient visits can be completed by Telehealth (documentation requirements are listed below). Finally, although the retention criteria is intended to be met each year, Homeless CMI patients that do not meet the retention requirements in the immediate subsequent year will not qualify for this class. If they meet the requirements in the second year following classification, they will be place in the Homeless CMI class. Due to the comprehensive nature of the treatment regimens, CMI patients are not assessed for Vesting CPT codes. Documentation Requirements for Telehealth Workload: Workload performed by a Telehealth procedure is documented as a secondary DSS Clinic Stop (CS) that identifies the type of Telehealth procedure performed. 1. SINGLE Encounter entered by the PROVIDER:DSS CS 179 for patients in their homes, DSS CS 648 for patients at non-VA site such as Vet. Center or Indian Health Centers. OR TWO Telehealth clinic stops entered for the same calendar date of care that identifies the PATIENT and the PROVIDER’s location. Patient location options include: * DSS CS 690: General TH Real Time: records data at the patient’s location. * DSS CS 644: Patient at National TH Center with real time video with provider.Provider location options include:* DSS CS 645: Provider at National TH Center* DSS CS 692: General TH Real Time provider at same station, or* DSS CS 693: General TH Real time provider NOT at same station as patient Non-VA or Contracted Care: A non-VA PTF is required for non-VA care to the Homeless population with a mental health diagnosis and 15 BDOC. The non-VA PTF is mandatory for this class because the ICD-9 diagnosis code is required as a secondary code and the Fee Payment files do not necessarily include secondary diagnosis codes. Homeless CMI patient class cannot be attained through purchased outpatient services as outpatient care is restricted to VHA care. Changes to the Homeless CMI class for VERA 2013: None. Care and Price Group: Complex Care; Price Group #9 - Chronic Mental Illness. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: Annual - for the Homeless CMI patient class. Beginning with FY2009, a patient meeting the definition of homeless noted above will retain the designation for two subsequent years, with or without additional documentation of codes indicating homelessness in the two subsequent years. Patients with a minimum of 41 Homeless CMI visits will be retained in the Homeless CMI patient class. Fiscal Year 2010 forward DSS Clinic Stops for the Homeless CMI Patient Class. For initial classification, at least 41 visits (days of care) to any of the clinic stops designated as “individual” listed below. Group visits are not considered as part of the required 41 individual visits required for this class. Note that a visit equates to a VHA day of care (regardless of how many CS are recorded in a single day). There are no non-VA substitutions for the care identified by the DSS Clinic Stops below. Primary CSClinic Name121RESID CARE PROGRAM FOLLOW-UP - INDIVIDUAL156HBPC PSYCHOLOGIST- INDIVIDUAL 157HBPC PSYCHIATRIST – INDIVIDUAL 502MENTAL HEALTH (MH) CLINIC - INDIVIDUAL503MH RESIDENTIAL CARE - INDIVIDUAL505DAY TREATMENT - INDIVIDUAL506DAY HOSPITAL - INDIVIDUAL509PSYCHIATRY - INDIVIDUAL510PSYCHOLOGY - INDIVIDUAL511HOMELESS GRANT AND PER DIEM- INDIVIDUAL (added FY11)512MH CONSULTATION - INDIVIDUAL513SUBSTANCE USE DISORDER - INDIVIDUAL514SUBSTANCE USE DISORDER HOME VISIT- INDIVIDUAL 519SUBSTANCE USE DISORDER (PTSD TEAMS) - INDIVIDUAL522DEPT HOUSING & URBAN DEV. (HUD)-VA SHARED HOUSING (VASH) –INDIVIDUAL 524ACTIVE DUTY SEX TRAUMA -INDIVIDUAL 525WOMEN STRESS DISORDER TREATMENT TEAMS - INDIVIDUAL529HEALTH CARE FOR HOMELESS VETERANS (HCHV/HCMI) -INDIVIDUAL 532PSYCHOSOCIAL REHAB - INDIVIDUAL 534 MH INTEGRATED CARE -INDIVIDUAL 535MH VOCATIONAL ASSISTANCE - INDIVIDUAL 538PSYCHOLOGICAL TESTING- INDIVIDUAL 540PCT POST-TRAUMATIC STRESS - INDIVIDUAL548INTENSIVE SUBSTANCE USE DISORDER – INDIVIDUAL 552MENTAL HEALTH INTENSIVE CASE MANAGEMENT - INDIVIDUAL562PTSD - INDIVIDUAL564MENTAL HEALTH TEAM CASE MANAGEMENT - INDIVIDUAL568MENTAL HEALTH (MH) COMPENSATED WORK THERAPY (CWT)/SE-INDIVIDUAL 571SERVICES FOR RETURNING VETERANS - MENTAL HEALTH -INDIVIDUAL 573MENTAL HEALTH INCENTIVE THERAPY FACE-TO-FACE -INDIVIDUAL 574MH COMPENSATED WORK THERAPY/TWE - INDIVIDUAL 576PSYCHOGERIATRIC CLINIC - INDIVIDUAL582PSYCHOSOCIAL REHABILITATION RECOVERY CENTER (PRRC) INDIVIDUAL588RRTP AFTERCARE- INDIVIDUAL (added FY1012)590COMM. OUTREACH TO HOMELESS VETS (OTHER THAN HCHV & PRRC) - INDIVIDUAL 591INCARCERATED VETERANS RE-ENTRY- INDIVIDUAL 592VETERANS JUSTICE OUTREACH-INDIVIDUAL 593RESIDENTIAL REHAB. TREATMENT PROGRAM (RRTP) OUTREACH - INDIVIDUAL 594RRTP AFTERCARE-COMMUNITY - INDIVIDUAL (to be replaced by 588 in FY 12)?595RRTP AFTERCARE-VA- GROUP (changed to Group visit in fy 11) 596RRTP ADMISSION SCREENING SERVICES - INDIVIDUAL Legacy LTC/Intermediate XE "Legacy-LTC/Intermediate" (Class # 44 in the Patient Classification hierarchy)A. Patient Class Overview: The Legacy LTC/Intermediate patient class is based on utilization criteria (BDOC) accrued in specific intermediate bed sections. The Legacy LTC/Intermediate class criterion requires at least 31 Bed Days of Care (BDOC) in an intermediate bed setting. In addition, patients residing in a Community Living Center (CLC) for more than 28 BDOC without a RUG III score in the preceding 12 months will also be placed in this class. Data Sources(s) and Class Criteria: The data source for the Legacy LTC patient class includes the Patient Treatment File (PTF) to determine the BDOC for the classification period. The BDOC are counted from the reporting date in the given fiscal year and extend back to the date of admission in the respective intermediate treating specialty, even if the initial admission occurred in a prior fiscal year. All BDOC acquired in the following VHA Intermediate Treating Specialties qualify for this patient class:#Treating Specialty Name32Intermediate Medicine GEM40Intermediate MedicineIn addition to intermediate BDOC, patients with a minimum of 28 BDOC in a CLC bed setting that do not have a RUG III Full Assessment score will default into this class instead of a CLC patient class that is higher on the classification hierarchy. A rolling 12 months of RUG III data is used to ensure all full assessment RUG scores are considered at the time of classification. Non-VA or Contracted Care: CNH BDOC will count towards the total required BDOC when they are accumulated in combination with other VHA Intermediate BDOC and when a PTF is completed for the CNH length of stay. Criteria changes to the Legacy LTC/Intermediate patient class for VERA 2013: No Changes. This was a new class for the VERA 2010 Model that is intended to capture patients residing in intermediate care beds (that are not certified for long term care). In addition, patients in a CLC bed for at least 28 BDOC without a RUG III score are defaulted into this class. Care and Price Group: Complex Care Group, Price Group #8 - Supportive Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by TRICARE and Sharing Agreements are VERA-funded. Classification Timeframe: Annual. A patient must meet the Legacy LTC/Intermediate class criteria each fiscal year. Long Stay Community Living Center (CLC) XE "Long Stay Community Living Center" (Class # 60 in the Patient Classification hierarchy)Patient Class Overview: The Long Stay CLC patient class is a long term patient class based on utilization criteria in a VHA Community Living Center (CLC). The Long Stay CLC class requires at least 91 Bed Days of Care (BDOC) in a designated CLC bed section, which is identified by Treating Specialty below and a RUG score. Data Sources(s) and Class Criteria: The data sources used to determine the actual BDOC for the classification period include the Patient Treatment Files (PTF) and quarterly Census files. The BDOC are counted from the reporting date in the given fiscal year and extend back to the date of admission in a CLC treating specialty, even if the initial admission occurred in a prior fiscal year. Pass and ABO days are excluded in the calculation of BDOC. Patients that were in the Long Stay CLC class in the immediate preceding year must have at least 91 BDOC in the current fiscal year to be placed in this class. In addition, patients are required to have at least one RUGs III full assessment during the prior 12 months. All BDOC in the following VHA CLCs qualify towards the required 91 BDOC for this patient class:VHA Treating Specialty (TS) for Community Living CentersTreating Specialty Codes and NameCodes NameCodesNameCodesName42/1PDementia Care47/1TRespite care69/1YSS Dementia care43*Skilled nursing care 64/1URehabilitation95/2ASkilled Nursing care44/1QLS Continuing Care66/1VRestorative care96/2BHospice45/1RLS MH Recovery 67/1WShort Stay (SS) Cont. care 1ASS GRECC46/1SSCI and Disorders68/1XSS MH recovery1CSS GRECC-GEM1BLS Stay GRECC81/1ZGeriatric Evaluation and Management (GEM)*TS 43 Skilled nursing care discontinued October 2011.Note: For the purposes of monthly classification that is less than a full fiscal year, a rolling 12 months of RUG III full assessments is used, which may include assessments completed in a prior fiscal year. In addition, because it is not uncommon for Long Stay CLC BDOC to span fiscal years, the classification process ensures that BDOC credit is not doubly counted in subsequent classification years. A patient must meet the required BDOC each subsequent year. Non-VA or Contracted Care: This class is exclusively for VHA CLC residents. It does not include non-VA care or Community Nursing Home patients. Criteria changes for VERA 2013: Patients in the Long Stay patient class are eligible for a high cost payment when their FY 2011 annual costs exceed the Long Stay high cost threshold of $218,000. VISNs will receive a high cost payment equal to the amount in excess of the Long Stay threshold of $218,000. Note that the high cost threshold is computed each year to ensure that the payment accurately reflect the costs of the respective VERA Model. Care Group and Price Group: Complex Care group, Price Group #10A: Long Stay CLC. This Price Group includes all VERA-funded patients. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients, with the exception of the 10A Price Group, which has one price for patients in Enrollment Priority Groups 1-8. While all Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded, note that the Long Stay (LS) patient population is the only Complex Care class that is not a forecasted value for the purposes of VERA funding. Instead, VERA funds the actual number of LS VERA-eligible patients for the latest data year (FY11 for VERA 2013.) This process ensures minimum levels of funding and protects against projected decreases in this costly LS populationClassification Timeframe: Annual. A patient must meet the classification criteria each fiscal year. Mental Health Intensive Case Management (MHICM) XE "Mental Health Intensive Case Management (MHICM)" (Class # 52 in the Patient Classification hierarchy)Patient Class Overview:The Mental Health Intensive Case Management (MHICM) patient class is based exclusively on utilization criteria equivalent to 41 visits (days of care) to the VHA Mental Health Intensive Case Management outpatient clinic (552). The MHICM clinic is governed by VHA Directive 2006-004, which explicitly defines the target population for treatment in a MHICM clinic. In light of the Directive’s requirements, the ARC does not assess the patient's diagnosis for inclusion in the MHICM patient class. Furthermore, because of the comprehensive treatment regimen provided to MHICM patients, these patients are not screened for a vesting CPT code. Patients in the MHICM class require extensive care in an outpatient environment for severe mental illness. The MHICM patient class first appeared in the VERA 2002 model, and is designed to provide Complex Care funding for mental health patients receiving extensive treatment in an outpatient setting in lieu of 41 inpatient bed days of care. The MHICM class includes patients that are high-intensity users of VA's mental health services. Data Sources(s) and Class Criteria:Initial Classification criteria:The data source for the MHICM patient class is the National Patient Care Database (NPCD) and includes workload from the Inpatient Encounter files. A patient is included in the MHICM patient class with a fiscal year minimum of 41 visits (days of care) to the Mental Health Intensive Case Management clinic designated as clinic stop 552. Note that while MHICM is considered an outpatient clinic, patients in the hospital can receive care in DSS Clinic Stop 552. The workload is tracked in the Inpatient Encounter (IE) file and is considered in the classification process. Also, the MHICM directive (VHA Directive 2006-004) references other clinic stops (546 and 564), however, these clinic stops are not valid criteria for the MHICM patient class. MHICM patients are not screened for diagnosis or a vesting CPT code.Subsequent Classification YearsPatients that continue to have a minimum of 41 visits (outpatient or IE visits) to MHICM clinic stop 552 will remain in the MHICM patient class. However, in subsequent classification years, MHICM patients that have a primary diagnosis consistent with the following CMI mental health classes: Other Psychosis, Schizophrenia and Dementia, Post Traumatic Stress Disorder (PTSD) - Chronic will be reclassified into the class that corresponds with their initial chronic mental health diagnosis when they entered the MHICM program. These re-classified patients must meet the CMI retention criteria in each successive classification year to remain in the CMI mental health class. Patients that do not meet CMI Registry criteria will not be included in the patient class. CMI Annual Retention Criteria The CMI Annual Retention Criteria identifies a series of treatment regimens that when met will retain the patient in the CMI Mental Health Class in the subsequent classification year. The treatment regimens include: At least 7 inpatient BDOC (pass and ABO days excluded) with a principal psychiatric diagnosis. The required principal diagnoses include all diagnoses in the MS Diagnostic Related Groups MS-DRGs 876, 880-887, 894-897. Inpatient care can occur in a VHA or non-VA setting provided a PTF is completed for the admission, or VHA outpatient care that equates to at least 6 VHA individual outpatient visits*, orat least 11 VHA group outpatient visits.**Note that the outpatient workload includes data from the Inpatient Encounter file and can be performed by certain Telehealth procedures when they are appropriately documented in the NPCD. There are no restrictions on the number of visits that can be performed by the Telehealth visits documented below. The outpatient care visits are identified by specific Clinic Stops, which are listed on p. 83 or in Appendix D. Outpatient care must be provided by a VHA source, as Non-VA care is not considered part of the CMI Retention Criteria. Beginning in FY2008, these outpatient visits can be completed by Telehealth (documentation requirements are listed below.) Furthermore, the annual requirement must be met each year following the initial classification year for the patient to remain in the CMI registry. Due to the comprehensive nature of the treatment regimens, CMI patients are not assessed for Vesting CPT codes. Documentation Requirements for Telehealth Workload: Workload performed by a Telehealth procedure is documented as a secondary DSS Clinic Stop (CS) that identifies the type of Telehealth procedure performed. 1. SINGLE Encounter entered by the PROVIDER:DSS CS 179 for patients in their homes, DSS CS 648 for patients at non-VA site such as Vet. Center or Indian Health Centers. OR TWO Telehealth clinic stops entered for the same calendar date of care that identifies the PATIENT and the PROVIDER’s location. Patient location options include: * DSS CS 690: General TH Real Time: records data at the patient’s location. * DSS CS 644: Patient at National TH Center with real time video with provider.Provider location options include:* DSS CS 645: Provider at National TH Center* DSS CS 692: General TH Real Time provider at same station, or* DSS CS 693: General TH Real time provider NOT at same station as patient Non-VA or Contracted Care: The MHICM class is exclusively for patient receiving VHA care. The MHICM class criteria cannot be met by non-VA or contracted mental health care services. Changes to the MHICM class for VERA 2013: No changes. Changes were made to the CMI Annual Retention criteria for VERA 2010 to allow certain outpatient workload to be performed by Telehealth procedures. Telehealth is documented in the secondary clinic stop position. Care and Price Group: Complex Care; Price Group #9 - Chronic Mental Illness. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe:Annual - for the MHICM patient class. However, in the subsequent year, a patient with a principal/primary diagnosis consistent with the Other Psychosis, Schizophrenia and Dementia, or Post Traumatic Stress Disorder (PTSD) – Chronic patient class will be re-classified to the respective class if s/he meets the minimum CMI Annual Retention Criteria. Patients with a minimum of 41 MHICM visits will be retained in the MHICM patient class. Other Psychosis XE "Other Psychosis" (Class # 50 in the Patient Classification hierarchy)A. Patient Class Overview:The Other Psychosis patient class is based on utilization and diagnosis criteria. Patients in this class must have at least 41 BDOC in an inpatient setting and a specific principal diagnosis. The Other Psychosis patient class is part of the Chronic Mental Illness (CMI) registry, which started in fiscal year 1989. In years following the initial classification year, these patients are retained in this class when a specific annual treatment regimen is met. Data Sources(s) and Class Criteria: The data source for the initial classification of Other Psychosis patients is the Patient Treatment File (PTF) N501 transaction file. In years following the initial classification into this patient class, the PTF and the National Patient Care Database (NPCD) are used to document the inpatient and outpatient care. Patients are included in the Other Psychosis patient class when they receive at least 41 Bed Days of Care (BDOC) of inpatient treatment with a principal psychiatric diagnosis, where at least one BDOC is for a principal diagnosis listed below: ICD-9 codeName296.XXAffective Psychoses297.XXParanoid States298.XXOther Nonorganic Psychoses The precise bed location of care for the inpatient stay is not a classification factor. For example, some (or all) of the inpatient care may occur in a Domiciliary provided the patient has a principal diagnosis from the list above. As with all BDOC requirements, the days of care do not need to be consecutive, and may occur over the course of many admissions during the fiscal year. Subsequent Classification YearsIn subsequent classification years, CMI patients in the following mental health classes: Other Psychosis, Schizophrenia and Dementia, Post Traumatic Stress Disorder (PTSD) - Chronic will be retained in that respective class if they meet the "CMI Annual Retention Criteria." CMI patients must meet the annual retention criteria each successive classification year to remain in the CMI mental health class. Patients that do not meet CMI Registry criteria will not be included in the patient class. CMI Annual Retention Criteria The CMI Annual Retention Criteria identifies a series of treatment regimens that when met will retain the patient in the CMI Mental Health Class in the subsequent classification year. The treatment regimens include: At least 7 inpatient BDOC (pass and ABO days excluded) with a principal psychiatric diagnosis. The required principal diagnoses include all diagnoses in the MS Diagnostic Related Groups MS-DRGs 876, 880-887, 894-897. Inpatient care can occur in a VHA or non-VA setting provided a PTF is completed for the admission, orVHA outpatient care that equates to at least 6 VHA individual outpatient visits*, orat least 11 VHA group outpatient visits.**Note that the outpatient workload includes data from the Inpatient Encounter file and can be performed by certain Telehealth procedures when they are appropriately documented in the NPCD. There are no restrictions on the number of visits that can be performed by the Telehealth visits documented below. The outpatient care visits are identified by specific Clinic Stops, which are listed on p. 83 or in Appendix D. Outpatient care must be provided by a VHA source, as Non-VA care is not considered part of the CMI Retention Criteria. Beginning in FY2008, these outpatient visits can be completed by Telehealth (documentation requirements are listed below). Furthermore, the annual requirement must be met each year following the initial classification year for the patient to remain in the CMI registry. Due to the comprehensive nature of the treatment regimens, CMI patients are not assessed for Vesting CPT codes. Documentation Requirements for Telehealth Workload: Workload performed by a Telehealth procedure is documented as a secondary DSS Clinic Stop (CS) that identifies the type of Telehealth procedure performed. 1. SINGLE Encounter entered by the PROVIDER:DSS CS 179 for patients in their homes, DSS CS 648 for patients at non-VA site such as Vet. Center or Indian Health Centers. OR TWO Telehealth clinic stops entered for the same calendar date of care that identifies the patient and the provider location. Patient location options include: * DSS CS 690: General TH Real Time: records data at the patient’s location. * DSS CS 644: Patient at National TH Center with real time video with provider.Provider location options include:* DSS CS 645: Provider at National TH Center* DSS CS 692: General TH Real Time provider at same station, or* DSS CS 693: General TH Real time provider NOT at same station as patient Non-VA or Contracted Care: The Fee Payment Files can be a data source for non-VA hospitalizations that are paid for by the VA., however, BDOC accumulated in a Non-VA setting (including a Community Nursing Home) must be documented in a non-VA PTF. Contracted outpatient care does not meet the CMI Retention Criteria. Criteria changes to the Other Psychosis patient class for VERA2013: No changes. Care and Price Group: Complex Care Group, Price Group #9 - Chronic Mental Illness. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe:Multi-year Classification. Following the initial classification year, a patient must meet the CMI Annual Retention Criteria each year to remain in this patient class. A patient is dropped from the Other Psychosis patient class when s/he does not meet the minimum requirements of the CMI Annual Retention Criteria.Polytrauma XE "Polytrauma" (Class # 55 in the Patient Classification hierarchy)Patient Class Overview: The Polytrauma patient class was a new class for the VERA 2012 Model. This class identifies patients that have had an inpatient stay in a VHA Polytrauma unit. The Polytrauma class requires at least one Bed Day of Care (BDOC) in a designated Polytrauma bed section, which is identified by Treating Specialty 1N. In addition, the Polytrauma Program Offices reviews and confirms the patients that qualify for this patient class. Data Sources(s) and Class Criteria: The data sources used to determine the actual BDOC for the classification period include the Patient Treatment Files (PTF) and quarterly Census files. The patient’s diagnosis is not a classification factor, only that the patient has at least one BDOC in a designated Polytrauma unit, where the treating section is identified as Treating Specialty 1N and confirmation of care by the Polytrauma Program Office. Additionally, unlike other Complex care patient classes, all Polytrauma patients, including patients with an eligibility status of Tricare or Sharing Agreement will be VERA-funded.? In the immediate three subsequent fiscal years following a discharge from a Polytrauma unit, a Polytrauma patient will fall no lower than the Traumatic Brain Injury (TBI)/Polytrauma patient class (class number 38 in Price Group 7) when s/he presents for either inpatient or outpatient care. Below is a list of the Polytrauma Centers.Polytrauma Rehabilitation Center Locations?Hunter Holmes McGuire VA Medical Center?Richmond, VAJames A. Haley Veterans' Hospital?Tampa, FLMinneapolis VA Medical Center?Minneapolis, MNVA Palo Alto Healthcare System?Palo Alto, CASouth Texas Texas Veterans Health Care System?San Antonio, TX Non-VA or Contracted Care: This class is exclusively for VHA Polytrauma Units. It does not include purchased or non-VA care. Criteria changes for VERA 2013: There were no changes to this class for the VERA 2013 process. This class was started in the VERA 2012 Model and identified patients based on at least one BDOC in a VHA Polytrauma unit. Unlike all other patient classes, non-VA patients including active military patients, patients on Tricare and Sharing agreements will be VERA funded. In addition, for the three immediate subsequent fiscal years, patients in this class will fall no lower than the TBI- Polytrauma class if they receive care provided or paid for by VHA. Care Group and Price Group: Complex Care group, Price Group #10: Critically Ill. All patients in the Polytrauma class, including patients with an eligibility status of Sharing Agreement and Tricare are VERA-funded. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients, with the exception of the 10A Price Group, which has one price for patients in Enrollment Priority Groups 1-8. All Complex care patients including those on Sharing Agreements or TRICARE are VERA-funded. Unlike other Complex care patient classes, all Polytrauma patients, including patients with an eligibility status of Tricare or Sharing Agreement will be VERA-funded.? Classification Timeframe: Annual. A patient must meet the classification criteria each fiscal year. For the three immediate subsequent fiscal years, patients in this class will fall no lower than the TBI- Polytrauma class if they receive care provided or paid for by VHA. PTSD – Chronic XE "PTSD – Chronic" (Class # 37 in the Patient Classification hierarchy)A. Patient Class Overview:The Post Traumatic Stress Disorder (PTSD) – Chronic patient class is based on utilization and diagnosis criteria. Patients in this class must have at least 41 BDOC in an inpatient setting and a specific principal diagnosis that is consistent with a Complex care mental health class (including the Substance Abuse class). At least one BDOC must be for the principal diagnosis of PTSD indicated by ICD-9 309.8X. The PTSD-Chronic patient class is part of the Chronic Mental Illness (CMI) registry, which started in fiscal year 1989. In years following the initial classification year, PTSD-Chronic patients are retained in this class when a specific annual treatment regimen is met. Data Sources(s) and Class Criteria: The data source for the initial classification of PTSD -Chronic patients is the Patient Treatment File (PTF) N501 transaction file. In years following the initial classification into the PTSD-Chronic patient class, the PTF and the National Patient Care Database (NPCD) are used to document the inpatient and outpatient care. The precise bed location of care for the inpatient stay is not a classification factor. For example, some (or all) of the inpatient care may occur in a Domiciliary provided the patient has a principal diagnosis of PTSD-Chronic (ICD-9 309.8X) for at least one of the inpatient admissions. As with all BDOC requirements, the days of care do not need to be consecutive, and may occur over the course of many admissions during the fiscal year. Subsequent Classification YearsIn subsequent classification years, CMI patients in the following mental health classes: Other Psychosis, Schizophrenia and Dementia, Post Traumatic Stress Disorder (PTSD) - Chronic will be retained in that respective class if they meet the "CMI Annual Retention Criteria." CMI patients must meet the annual retention criteria each successive classification year to remain in the CMI mental health class. Patients that do not meet CMI Registry criteria will not be included in the patient class. CMI Annual Retention Criteria The CMI Annual Retention Criteria identifies a series of treatment regimens that when met will retain the patient in the CMI Mental Health Class in the subsequent classification year. The treatment regimens include: At least 7 inpatient BDOC (pass and ABO days excluded) with a principal psychiatric diagnosis. The required principal diagnoses include all diagnoses in the MS Diagnostic Related Groups MS-DRGs 876, 880-887, 894-897. Inpatient care can occur in a VHA or non-VA setting provided a PTF is completed for the admission, orVHA outpatient care that equates to at least 6 VHA individual outpatient visits*, orat least 11 VHA group outpatient visits.**Note that the outpatient workload includes data from the Inpatient Encounter file and can be performed by certain Telehealth procedures when they are appropriately documented in the NPCD. There are no restrictions on the number of visits that can be performed by the Telehealth visits documented below. The outpatient care visits are identified by specific Clinic Stops, which are listed on p.83 or in Appendix D. Outpatient care must be provided by a VHA source, as Non-VA care is not considered part of the CMI Retention Criteria. Beginning in FY2008, these outpatient visits can be completed by Telehealth (documentation requirements are listed below). Furthermore, the annual requirement must be met each year following the initial classification year for the patient to remain in the CMI registry. Due to the comprehensive nature of the treatment regimens, CMI patients are not assessed for Vesting CPT codes. Documentation Requirements for Telehealth Workload: Workload performed by a Telehealth procedure is documented as a secondary DSS Clinic Stop (CS) that identifies the type of Telehealth procedure performed. 1. SINGLE Encounter entered by the PROVIDER:DSS CS 179 for patients in their homes, DSS CS 648 for patients at non-VA site such as Vet. Center or Indian Health Centers. OR TWO Telehealth clinic stops entered for the same calendar date of care that identifies the PATIENT and the PROVIDER’s location. Patient location options include: * DSS CS 690: General TH Real Time: records data at the patient’s location. * DSS CS 644: Patient at National TH Center with real time video with provider.Provider location options include:* DSS CS 645: Provider at National TH Center* DSS CS 692: General TH Real Time provider at same station, or* DSS CS 693: General TH Real time provider NOT at same station as patient Non-VA or Contracted Care: The Fee Payment Files are the data source for non-VA hospitalizations that are paid for by the VA, however, BDOC accumulated in a Non-VA setting (including a Community Nursing Home) must be documented in a non-VA PTF. Contracted outpatient care does not meet the CMI Retention Criteria. Criteria changes to the PTSD - Chronic patient class since VERA2013: No changes. Changes were made to the CMI Annual Retention criteria for VERA 2010 to allow certain outpatient workload to be performed by Telehealth procedures. Telehealth is documented in the secondary clinic stop position. Care Group and Price Group: Complex Care group, Price Group # 7 - Specialized Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: Multi-year Classification. Following the initial classification year, patients that meet the CMI Annual Retention Criteria will remain in this class. A patient is dropped from the PTSD-Chronic patient class when s/he does not meet the minimum requirements of the CMI Annual Retention Criteria. Residential Rehabilitation XE "Residential Rehabilitation" (Formerly known as Domiciliary Patient Class)(Class # 42 in the Patient Classification hierarchy)Patient Class Overview:The Residential Rehabilitation (RR) patient class, formerly known as the Domiciliary (Dom) patient class, is based exclusively on utilization criteria, which equates to a cumulative total of 91 Bed Days of Care (BDOC) in any of the Treating Specialties listed below. A patient's diagnosis is not a classification factor, and RUG scores are neither required nor used for this class. A patient is placed in this patient class with at least 91 BDOC from any of the following locations: a VA Dom., a VA Residential Rehabilitation Program (RRT), and intermediate or long term care bed section. Note that pass and ABO days are excluded from the total BDOC for the fiscal year. Data Sources(s) and Class Criteria:The PTF is the primary data source for the RR/Dom. class. The classification criterion is based exclusively on the total BDOC for the fiscal year. This class includes patients that spend a significant amount of time as an inpatient but have not qualified for a class that is higher on the classification hierarchy. Specifically, this class requires 91 BDOC in any of the Treating Specialties listed below. Treating SpecialtyNameTreating SpecialtyName25 or 1K*PRRTP38 or 39*PTSD CWT/TR26 or 1L*PTSD PRRP39CWT/TR27or 1M*Sub Abuse SARRTP85Domiciliary28 or 39*HCMI CWT/TR86Domiciliary Substance Abuse29 or 39*SA CWT/TR87Domiciliary GEM37Homeless Dom 88DOM-PTSD*Indicates change as of January 2010. It is important to note that patients residing in a Domiciliary or RRT program may fall into a patient class that is higher on the classification hierarchy due to other classification factors. For example, the CMI classes Other Psychosis or Schizophrenia and Dementia require only 41 BDOC in any VA bed setting, including a Domiciliary, when a patient presents with a specific mental health diagnosis. See the CMI patient class descriptions for precise list of diagnosis codes. Non-VA or Contracted Care: Residential bed days of care provided in settings outside of the VHA are not included in the RR patient class. For example, BDOC provided in contracted /non-VA domiciliary setting are not included in the RR patient class. Furthermore, state domiciliary care is not included in the RR patient class because it is paid from funds that are not accounted for in the VERA Model (i.e. VA Specific Purpose funds). Criteria Changes to the RR patient class criteria for VERA 2013: No changes were made to the Residential Rehabilitation (Dom.) patient class. Care Group and Price Group: Complex Care group, Price Group #8 – Supportive Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: Annual. Patients in the RR patient class must meet the utilization criteria each fiscal year. Schizophrenia and Dementia XE "Schizophrenia and Dementia" (Class #51 in the Patient Classification hierarchy)Patient Class Overview:The Schizophrenia and Dementia (S&D) patient class is based on utilization and diagnosis criteria. Patients in this class must have at least 41 BDOC in an inpatient setting and a specific principal diagnosis. The Schizophrenia and Dementia patient class is part of the Chronic Mental Illness (CMI) registry, which started in fiscal year 1989. In years following the initial classification year, Schizophrenia and Dementia patients are retained in this class when a specific annual treatment regimen is met. Data Sources(s) and Class Criteria:The data source for the initial classification of S&D patients is the Patient Treatment File (PTF) N501 transaction file. In years following the initial classification year, PTF and the National Patient Care Database (NPCD) are used to document either the BDOC or the required clinic stops for outpatient care. A patient is included in the Schizophrenia and Dementia patient class with 41 BDOC as an inpatient with a principal diagnosis of Schizophrenia or Dementia from the following list:Schiz/DemICD-9Description:Schiz295.XX*Schizophrenic DisorderDem290.XX*Senile & Pre-senile Organic Psychotic ConditionsDem294.XX*Other Organic Psychotic Conditions (Chronic)Dem310.XX*Specific Non-psychotic Mental Disorders due to Organic Brain DamageOR*A principal diagnosis of Alzheimer’s Disease (ICD-9 code 331.0X) AND a secondary diagnosis listed above or from the PTSD-Chronic, Other Psychosis or Substance Abuse patient classes. Coding rules require that the Alzheimer’s diagnosis be listed as the principal diagnosis. As with all BDOC requirements, these days do not need to be consecutive, and may occur over the course of many admissions during the fiscal year. The precise bed location of care is not a classification factor for patients with a Schizophrenic Disorder diagnosis. For example, some or all of the inpatient BDOC may occur in a Domiciliary provided the patient has a principal diagnosis of Schizophrenia. When a patient has a principal diagnosis of Dementia, BDOC in intermediate, CLC or CNH ?bed sections do not qualify for this patient class.? Instead, Dementia patients may qualify for a higher class when the patient receives care in a VHA CLC.? All other bed sections count towards the required 41 BDOC.?? Subsequent Classification YearsIn subsequent classification years, CMI patients in the following mental health classes: Other Psychosis, Schizophrenia and Dementia, Post Traumatic Stress Disorder (PTSD) - Chronic will be retained in that respective class if they meet the "CMI Annual Retention Criteria." CMI patients must meet the annual retention criteria each successive classification year to remain in the CMI mental health class. Patients that do not meet CMI Registry criteria will not be included in the patient class. CMI Annual Retention Criteria The CMI Annual Retention Criteria identifies a series of treatment regimens that when met will retain the patient in the CMI Mental Health Class in the subsequent classification year. The treatment regimens include: At least 7 inpatient BDOC (pass and ABO days excluded) with a principal psychiatric diagnosis. The required principal diagnoses include all diagnoses in the MS Diagnostic Related Groups MS-DRGs 876, 880-887, 894-897. Inpatient care can occur in a VHA or non-VA setting provided a PTF is completed for the admission, or VHA outpatient care that equates to at least 6 VHA individual outpatient visits*, orat least 11 VHA group outpatient visits.**Note that the outpatient workload includes data from the Inpatient Encounter file and can be performed by certain Telehealth procedures when they are appropriately documented in the NPCD. There are no restrictions on the number of visits that can be performed by the Telehealth visits documented below. The outpatient care visits are identified by specific Clinic Stops, which are listed in H. below and Appendix D. Outpatient care must be provided by a VHA source, as Non-VA care is not considered part of the CMI Retention Criteria. Beginning in FY2008, these outpatient visits can be completed by Telehealth (documentation requirements are listed below.) Furthermore, the annual requirement must be met each year following the initial classification year for the patient to remain in the CMI registry. Due to the comprehensive nature of the treatment regimens, CMI patients are not assessed for Vesting CPT codes. Documentation Requirements for Telehealth Workload: Workload performed by a Telehealth procedure is documented as a secondary DSS Clinic Stop (CS) that identifies the type of Telehealth procedure performed. 1. SINGLE Encounter entered by the PROVIDER:DSS CS 179 for patients in their homes, DSS CS 648 for patients at non-VA site such as Vet. Center or Indian Health Centers. OR TWO Telehealth clinic stops entered for the same calendar date of care that identifies the PATIENT and the PROVIDER’s location. Patient location options include: * DSS CS 690: General TH Real Time: records data at the patient’s location. * DSS CS 644: Patient at National TH Center with real time video with provider.Provider location options include:* DSS CS 645: Provider at National TH Center* DSS CS 692: General TH Real Time provider at same station, or* DSS CS 693: General TH Real time provider NOT at same station as patient Non-VA or Contracted Care: The Fee Payment Files can be a data source for non-VA hospitalizations that are paid for by the VA, however, BDOC accumulated in a Non-VA setting (including a Community Nursing Home) must be documented in a non-VA PTF. Contracted outpatient care does not meet the CMI Retention Criteria. Criteria changes to the Schizophrenia and Dementia patient class since VERA2013: No changes. Care Group and Price Group: Complex Care group, Price Group #9 - Chronic Mental Illness. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe:Multi-year Classification. Following the initial classification year, patients that meet the CMI Annual Retention Criteria will remain in this patient class. A patient is dropped from the Schizophrenia and Dementia patient class when s/he does not meet the minimum requirements of the CMI Annual Retention Criteria. VERA 2013 DSS Clinic Stops for the CMI Retention Criteria XE " VERA 2013 DSS Clinic Stops for the CMI Retention Criteria " This list identifies the CMI Annual Retention Criteria "supportive psychiatric services" by Primary DSS Clinic Stop (CS) for the CMI classes (Homeless CMI, PTSD Chronic, Other Psychosis, and Schizophrenia & Dementia.) Every year following the initial classification year, a CMI patient (or MHICM patient with a CMI-diagnosis) must receive at least 6 individual VHA outpatient psychiatric visits, or at least 11 VHA group psychiatric visits to be retained in the CMI class. The DSS CS’s are categorized as either an "INDIVIDUAL" or a "GROUP" visit. Note that a visit equates to a VHA day of care (regardless of how many CS are recorded in a single day). Workload performed by Telehealth (TH) must be documented as a Secondary CS (or credit pair) of 179 for Real Time Videoconferencing for a patient at home or DSS CS 648 when patient at a non-VA site such as a Vet Center. When a patient is at a station, CS 690 or 644 indicates the location of the patient. A corresponding entry (for the same calendar day) is required for the provider’s location: DSS CS 692 for the same station or 693 for a station that is different from the patient, 645 for National TH center. Finally, non-VA care does not qualify for the outpatient component of the CMI Annual Retention Criteria. Primary CSClinic Name121RESID CARE PROGRAM FOLLOW-UP - INDIVIDUAL156HBPC PSYCHOLOGIST- INDIVIDUAL (added fy 10)157HBPC PSYCHIATRIST – INDIVIDUAL (added fy 10)502MENTAL HEALTH CLINIC - INDIVIDUAL503MH RESIDENTIAL CARE - INDIVIDUAL504GRANT AND PER DIEM – GROUP (added in fy12)505DAY TREATMENT - INDIVIDUAL506DAY HOSPITAL - INDIVIDUAL507HUD/VA SUPPORTED HOUSING (VASH) –GROUP (added fy12)508HCHV/HCMI – GROUP (added fy12)509PSYCHIATRY - INDIVIDUAL510PSYCHOLOGY - INDIVIDUAL511HOMELESS GRANT AND PER DIEM – INDIVIDUAL (added fy 11)512MENTAL HEALTH CONSULTATION - INDIVIDUAL513SUBSTANCE USE DISORDER - INDIVIDUAL514SUBSTANCE USE DISORDER HOME VISIT- INDIVIDUAL 516PTSD GROUP - GROUP519SUBSTANCE USE DISORDER (PTSD TEAMS) - INDIVIDUAL522DEPT HOUSING & URBAN DEV. (HUD)-VA SHARED HOUSING (VASH) –INDIVIDUAL (added fy 10)523OPIOD SUBSTITUTION (Considered as a GROUP visit requiring at least 11 visits in a year )524ACTIVE DUTY SEX TRAUMA -INDIVIDUAL 525WOMEN STRESS DISORDER TREATMENT TEAMS - INDIVIDUAL529HEALTH CARE FOR HOMELESS VETERANS (HCHV/HCMI) -INDIVIDUAL 532PSYCHOSOCIAL REHAB - INDIVIDUAL (inactivated 10-1-12)534 MH INTEGRATED CARE -INDIVIDUAL (added 10-1-07)535MH VOCATIONAL ASSISTANCE - INDIVIDUAL (added 10/1/08)538PSYCHOLOGICAL TESTING- INDIVIDUAL (added 10/1/08)539MH INTEGRATED CARE-GROUP (added 10/1/10)540PCT POST-TRAUMATIC STRESS - INDIVIDUAL547INTENSIVE SUBSTANCE USE DISORDER - GROUP 548INTENSIVE SUBSTANCE USE DISORDER – INDIVIDUAL (added fy 10)550MENTAL HEALTH CLINIC - GROUP552MENTAL HEALTH INTENSIVE CASE MANAGEMENT - INDIVIDUAL553DAY TREATMENT - GROUP 554DAY HOSPITAL - GROUP 557PSYCHIATRY - GROUP558PSYCHOLOGY – GROUP (inactivated 10-1-12)559PSYCHOSOCIAL REHAB - GROUP560SUBSTANCE USE DISORDER - GROUP561PCT-POST TRAUMATIC STRESS - GROUP562PTSD - INDIVIDUAL564MENTAL HEALTH TEAM CASE MANAGEMENT - INDIVIDUAL566MENTAL HEALTH RISK-FACTOR REDUCTION ED. – GROUP (added fy10)567MENTAL HEALTH INTENSIVE CASE MANAGEMENT (MHICM) - GROUP 568MENTAL HEALTH (MH) COMPENSATED WORK THERAPY (CWT)/SE-INDIVIDUAL (added 10/1/08)571SERVICES FOR RETURNING VETERANS - MENTAL HEALTH -INDIVIDUAL 572SERVICES RETURNING VETERANS & CARE - GROUP 573MENTAL HEALTH INCENTIVE THERAPY FACE-TO-FACE -INDIVIDUAL (added 10/1/08)574MH COMPENSATED WORK THERAPY/TWE - INDIVIDUAL (added 10/1/08)575MH VOCATIONAL ASSISTANCE - GROUP (added 10/1/08)576PSYCHOGERIATRIC CLINIC - INDIVIDUAL577PSYCHOGERIATRIC CLINIC - GROUP580PTSD DAY HOSPITAL (Considered as a GROUP visit requiring at least 11 visits.)582PSYCHOSOCIAL REHABILITATION RECOVERY CENTER (PRRC) INDIVIDUAL 583PSYCHOSOCIAL REHABILITATION RECOVERY CENTER (PRRC) GROUP 588RRTP AFTERCARE- INDIVIDUAL (added FY1012)590COMM. OUTREACH TO HOMELESS VETS (OTHER THAN HCHV & PRRC) - INDIVIDUAL 591INCARCERATED VETERANS RE-ENTRY- INDIVIDUAL (added 10-1-07)592VETERANS JUSTICE OUTREACH-INDIVIDUAL (added fy 10)593RESIDENTIAL REHAB. TREATMENT PROGRAM (RRTP) OUTREACH - INDIVIDUAL (added fy 10)594RRTP AFTERCARE-COMMUNITY - INDIVIDUAL (replaced by 588 in FY12)?595RRTP AFTERCARE-VA- GROUP (changed to Group visit in fy 11)596RRTP ADMISSION SCREENING SERVICES - INDIVIDUAL (added fy 10)598RRTP ADMISSION SCREENING SERVICES – PRE-ADMISSION-INDIVIDUAL (added fy 12)599RRTP ADMISSION SCREENING SERVICES – PRE-ADMISSION-GROUP (added fy 12)?Short Stay Community Living Center (CLC) XE "Short Stay Community Living Center (CLC)" (Class # 53 in the Patient Classification hierarchy)Patient Class Overview: The Short Stay CLC patient class is a long term patient class based on utilization criteria in a VHA Community Living Center (CLC.) The Short Stay CLC class requires at least 28 Bed Days of Care (BDOC) in a designated CLC bed section, which is identified by Treating Specialty below. Patients with greater than 90 CLC BDOC are placed in the Long Stay CLC patient class. Data Sources(s) and Class Criteria: The data sources used for the Short Stay CLC Complex patient class includes the Patient Treatment Files (PTF) and quarterly Census files to determine the number of BDOC for the classification period. The BDOC are counted from the reporting date in the given fiscal year and extend back to the date of admission in a CLC treating specialty, even if the initial admission occurred in a prior fiscal year. Pass and ABO days are excluded in the calculation of BDOC. In addition, patients are required to have at least one RUGs III full assessment during the prior 12 months. All BDOC acquired in the following VHA CLCs qualify towards the required 28 BDOC for this patient class:VHA Treating Specialty (TS) for Community Living CentersTreating Specialty Code and Name# Name#Name#Name42/1PDementia Care47/1TRespite care69/1YSS Dementia care43*Skilled nursing care 64/1URehabilitation95/2ASkilled Nursing care44/1QLS Continuing Care66/1VRestorative care96/2BHospice45/1RLS MH Recovery 67/1WShort Stay (SS) Cont. care 1ASS GRECC46/1SSCI and Disorders68/1XSS MH recovery1CSS GRECC-GEM1BLS Stay GRECC81/1ZGeriatric Evaluation and Management (GEM)*TS 43 Skilled nursing care was discontinued October 2011. Note: For the purposes of monthly classification that is less than a full fiscal year, a rolling 12 months of RUG III full assessments is used, which may include assessments completed in a prior fiscal year. In addition, because it is not uncommon for CLC BDOC to span fiscal years, the classification process ensures that BDOC credit is not doubly counted in subsequent classification years. A patient must meet the required BDOC each subsequent year. Non-VA or Contracted Care: This class is exclusively for VHA CLC residents. It does not include non-VA care or Community Nursing Home patients. Criteria changes for VERA 2013: No changes: This was a new patient class in VERA 2010. This class captures many of the patients that previously qualified for the LTC classes in prior VERA Models with the exception of patients with BDOC in intermediate bed sections. Patients with greater than 90 CLC BDOC will qualify for the Long Stay CLC patient class that also did not exist in prior models. Care Group and Price Group: Complex Care group, Price Group #10; Short Stay CLC. This Price Group includes all VERA-funded patients. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients, with the exception of the 10A Price Group, which has one price for patients in Enrollment Priority Groups 1-8. All VERA-eligible patients will be funded. Classification Timeframe: Annual. A patient must meet the classification criteria each fiscal year. Skilled Nursing and Rehabilitation (CLC) XE "Skilled Nursing and Rehabilitation (CLC)" (Class #45 in the Patient Classification hierarchy)A. Patient Class Overview:The Rehabilitation patient class is a long term patient class that is based on utilization criteria accrued in either 1. A VHA Community Living Center (CLC) bed section whereby a specific RUG score indicating high levels of rehabilitation services or A Commission on Accreditation for Rehabilitation Facilities (CARF) accredited VHA bed section whereby the patient had high levels of rehabilitation services as evidenced by Common Procedure Terminology (CPT) codes during the fiscal year. Data Sources(s) and Class Criteria: For the VHA CLC bed settings identified by Treating Specialty (TS) code below, The data sources used for the Skilled Nursing and Rehabilitation patient class include the Patient Treatment File (PTF) to determine the total CLC BDOC (excluding pass and ABO days) during the fiscal year and the appropriate RUG III score obtained from the CDOC in Austin. Patients with 7 to 27 CLC BDOC in the following VHA CLC Treating Specialties qualify for this patient class:Treating Specialty Codes and NameCodes NameCodesNameCodesName42/1PDementia Care47/1TRespite care69/1YSS Dementia care43*Skilled nursing care 64/1URehabilitation95/2ASkilled Nursing care44/1QLS Continuing Care66/1VRestorative care96/2BHospice45/1RLS MH Recovery 67/1WShort Stay (SS) Cont. care 1ASS GRECC46/1SSCI and Disorders68/1XSS MH recovery1CSS GRECC-GEM1BLS Stay GRECC81/1ZGeriatric Evaluation and Management (GEM)TS 43 Skilled nursing care was discontinued October 2011. Patients must also have a Resident Assessment Instruments/ Minimum Data Set (RAI/MDS) full assessment with a RUG III Group of Rehabilitation plus Extensive Services, Rehabilitation, Extensive Services or Special Care. The precise qualifying scores include:RUG IIIADL ScoresRUG IIIADL ScoresRUG IIIADL ScoresRHAHigh, ADL 4-7RUCUltra High, ADL 16-18RMXADL 15-18RHBHigh, ADL 8-12RVAVery High, ADL 4-8RMLADL 7-14RHCHigh, ADL 13-18RVBVery High, ADL 9-15RLXADL 7-18RLALow, ADL 4-13RVCVery High, ADL 16-18SE10 or 1 ct, ADL > 6RLBLow, ADL 14-18RUXADL 16-18SE22 or 3 ct, ADL > 6RMAMedium, ADL 4-7RULADL 7-15SE34 or 5 ct, ADL > 6RMBMedium, ADL 8-14RVXADL 16-18SSAADL 7-14RMCMedium, ADL 15-18RVLADL 7-15SSBADL 15-16RUAUltra High, ADL 4-8RHXADL 13-18 SSCADL 17-18RUBUltra High, ADL 9-15RHLADL 7-12 For patients residing in VHA CARF accredited TS for Rehabilitative Medical Services Treating Specialties (TS) 20 and 82 and have received high levels of rehabilitation services that are documented in the Inpatient Encounter (IE) file or the National Patient Care Database (NPCD). In addition to an inpatient admission, patients must receive at least 15 hours of rehabilitative services in the fiscal year, which must be documented in the IE file or the NPCD using qualifying CPT codes. Each encounter form will be assessed for up to one hour of care based on the precise CPT codes that range from 97010 to 97546. Each qualifying code is valued at 15 minutes per code and the encounter is limited to a maximum of 60 minutes per form. Non-VA care is not considered for this patient classNon-VA or Contracted Care: BDOC in Community Nursing Homes (CNH) or non-VA hospitals do not qualify for this patient class. This class is restricted to BDOC acquired in a VHA CLCs or a VHA CARF accredited Treating Specialty. Criteria Changes for VERA 2013: This class was modified to include patients that received inpatient care in a Commission on Accreditation of Rehabilitative Facilities (CARF) accredited VHA bed section, including Treating Specialty 20 and 82. Care Group and Price Group: Complex Care group, Price Group #8 - Supportive Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: Annual. A patient must meet the Skilled Nursing and Rehabilitative patient class classification criteria each fiscal year. SCI Para – New Injury or Institutionalized XE "SCI Para – New Injury and Institutionalized" (Class #57 in the Patient Classification hierarchy)Patient Class Overview: This class includes Paraplegic spinal cord injury (SCI) patients in the first year of their “new” injury or patients that are institutionalized for their SCI condition. The SCI Paraplegia (Para) – New Injury component of this class is based on inpatient diagnosis criteria obtained from the Patient Treatment File (PTF). In addition to New Injury patients, this class includes patients that are institutionalized for their SCI diagnoses. The SCI Institutionalized component of this patient class includes SCI diagnosed patients with at least 28 BDOC in an SCI treating specialty (Treating Specialty 22), Community Living Center (CLC) or Community Nursing Home (CNH). When an SCI Para – New Injury or Institutionalized patient presents in a subsequent fiscal year, the patient is re-classified into the SCI Para – Old Injury patient class unless the patient qualifies for the institutionalized component of this class based on Bed Days of Care (BDOC). The SCI Classification Group is cumulative registry that contains patient entries beginning in fiscal year 1988.Data Sources(s) and Class Criteria: Inpatient: The data source for the SCI Para – New Injury component of this patient class is the Patient Treatment File (PTF) N501 transactions. Patients are classified as SCI Para -New Injury when any of the following ICD-9 Diagnosis Codes are identified in the PTF as either a principal or secondary diagnosis: 806.2X to 806.7X - Fracture of vertebral column with SCI; 952.1X - Spinal cord injury without evidence of spinal bone injury; dorsal [thoracic]952.2X - Spinal cord injury without evidence of spinal bone injury; lumbar952.3X - Spinal cord injury without evidence of spinal bone injury; sacral952.4X - Spinal cord injury without evidence of spinal bone injury; Cauda equinaSCI Institutionalized is defined as an SCI diagnosed patient with at least 28 Bed Days of Care (BDOC) in an SCI treating specialty (Treating Specialty 22) or CLC or CNH. NOTE: Patients with a pre-existing diagnosis of multiple sclerosis (340.xx) and a SCI diagnoses are included in this class only when they meet the institutionalized criteria. A new injury diagnosis code alone (without the required institutionalized BDOC) will not meet the requirements of this patient class. Outpatient: Outpatient care does not qualify for this patient class. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. The only non-VA care that qualifies for this class is Community Nursing Home (CNH). CNH care that is paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Criteria Changes to the SCI Para - New Injury/Institutionalized patient class for VERA 2013: SCI registry patients that exclusively receive telephone care or secure messaging in a fiscal year are placed in the most appropriate Basic care class. Care Group and Price Group: Complex Care, Price Group #10 - Critically Ill. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification TimeframeThe SCI Para-New Injury patient class (classification by diagnosis) is limited to once in a lifetime. However, an SCI Para-New Injury patient that does not meet the definition of institutionalized (28 BDOC in SCI Treating Specialty or CLC) and presents for inpatient or outpatient care in a subsequent year is re-classified into the SCI Para -Old Injury patient class (unless s/he qualifies for a class that is higher on the classification hierarchy). SCI Para – Old Injury XE "SCI Para – Old Injury" (Class # 46 in the Patient Classification hierarchy)Patient Class Overview: The SCI Paraplegic (Para) – Old Injury patient class is based on diagnosis criteria from the Patient Treatment File (PTF). In addition, this class includes patients that were previously classified as SCI Para-New Injury in a prior year and are not considered institutionalized. The SCI Classification Group (including the New SCI/Institutionalized classes and the Old Injury classes) are maintained in the ARC SCI registry that dates back to fiscal year 1988. It is important to note that patients in the SCI classes must have been admitted at least once since 1988 with a Principal or Secondary SCI diagnosis to be included in any of the SCI classes. Patients receiving exclusively outpatient care for the SCI condition without ever having been admitted for the SCI condition are excluded from the SCI patient classes. Data Sources(s) and Class Criteria: The data source for the SCI Para – Old Injury patient class is the Patient Treatment File (PTF) N501 transactions. Patients qualify for this class with a PTF ICD-9 Principal or Secondary Diagnosis Code of:344.1X – Paraplegia, or907.2 - Late effect of spinal cord injury (either ICD-9 code will qualify the patient as SCI Para - Old Injury)In addition, each patient that was classified as SCI Para-New Injury in a prior year is reclassified into the SCI Para-Old Injury patient class when s/he presents to the VHA in a subsequent year and does not meet the requirements for institutionalization. The data source for this patient class includes the PTF, NPCD (for patients already included in the SCI registry from a prior year) and the Fee Payment Files. SCI –Old Injury patients are “class protected”, meaning that an SCI-Old Injury patient will be retained in this class when the patient receives qualifying clinical care in a subsequent year. Note that encounters for telephone care, secure messaging and pharmacy prescription refills are not considered qualifying clinical care that would retain a patient in the SCI Old Injury class. Furthermore, fiscal year workload that exclusively includes telephone encounters or secure messaging will place the patient in the most appropriate Basic Vested class contingent upon the diagnosis and clinical codes used for the encounter(s). Workload that exclusively includes prescription refills will place the patient in the Pharmacy patient class. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Criteria Changes to the SCI Para - Old Injury class for VERA 2013: SCI Old Injury patients that exclusively receive telephone care or secure messaging in a fiscal year are placed in the most appropriate Basic Care patient class based on care received. Exclusively telephone workload or secure messaging does not qualify for this class. In subsequent years when other clinical workload is evident, the patient will be returned to the Old Injury patient class. Care and Price Group: Complex Care group, Price Group #8 - Supportive Care Price Group.Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: Permanent Classification. A patient will be retained in the SCI Para-Old Injury class in every subsequent year the patient presents to the VA for inpatient or outpatient care, unless the patient qualifies for a class that is higher on the patient classification hierarchy. Treatment does not need to occur in consecutive years. SCI Quad – New Injury or Institutionalized XE "SCI Quad – New Injury/Institutionalized" (Class #58 in the Patient Classification hierarchy)Patient Class Overview: This class includes Quadriplegic (Quad) spinal cord injury (SCI) patients in the first year of their “new” injury or patients that are institutionalized for their SCI condition. The SCI Quadriplegic (Quad) – New Injury component of this class is based on inpatient diagnosis criteria obtained from the Patient Treatment File (PTF). In addition to New Injury patients, this class includes patients that are institutionalized for their SCI condition. When an SCI Quad – New Injury patient presents in a subsequent fiscal year, the patient is re-classified into the SCI Quad – Old Injury patient class unless the patient qualifies for the institutionalized component of this class. SCI Institutionalized is defined as an SCI diagnosed patient with at least 28 Bed Days of Care (BDOC) from any of the following bed settings: SCI treating specialty (Treating Specialty 22), Community Living Center (CLC) or Community Nursing Home (CNH). The SCI Classification Group is cumulative registry that contains patient entries beginning in fiscal year 1988. Data Sources(s) and Class Criteria:Inpatient: The data source for the SCI Quad – New Injury patient class is the Patient Treatment File (PTF) N501 transactions. Patients qualify for the SCI Quad -New Injury patient class with a PTF ICD-9 Principal or Secondary Diagnosis Code of: 806.00 – 806.06 Fracture of vertebral column with SCI; 806.07 - C5-C7 level with anterior cord syndrome; closed806.08 - C5-C7 level with central cord syndrome; closed806.09 -C5-C7 level with other specified spinal cord injury; closed806.1X - Fracture of vertebral column with SCI; cervical; open806.8X - Fracture of vertebral column with SCI; unspecified; closed806.9X - Fracture of vertebral column with SCI; unspecified; open952.0X - Spinal cord injury without evidence of spinal bone injury; cervical952.8X - Spinal cord injury without evidence of spinal bone injury; multiple sites of spinal cord952.9X- Spinal cord injury without evidence of spinal bone injury; unspecified site of spinal cordSCI Institutionalized SCI Institutionalized is defined as an SCI patient with at least 28 Bed Days of Care (BDOC) in any of the following: SCI treating specialty (Treating Specialty 22), CLC or CNH. NOTE: Patients with pre-existing diagnosis of multiple sclerosis (340.xx) and SCI diagnoses are included in this class only when they meet the institutionalized criteria. A new injury diagnosis code alone (without the required institutionalized BDOC) will not meet the requirements of this patient class. Outpatient: Outpatient care does not qualify for this patient class. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. The only non-VA care that qualifies for this class is Community Nursing Home (CNH). CNH care that is paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codesCriteria Changes to the SCI Quad - New Injury/Institutionalized patient class for VERA 2013: No Changes. For VERA 2010 the required BDOC for the institutional designation was changed to 28 BDOC in either an SCI treating specialty or a CLC. BDOC acquired in Intermediate bed sections do not qualify as institutionalized. Care Group and Price Group: Complex Care group, Price Group #10 - Critically Ill. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: The SCI Quad-New Injury patient class (classification by diagnosis) is limited to once in a lifetime. However, an SCI Quad-New Injury patient that does not meet the definition of institutionalized (28 BDOC in SCI Treating Specialty or CLC) and presents for inpatient or outpatient care in a subsequent year is re-classified into the SCI Quad -Old Injury patient class (unless s/he qualifies for a class that is higher on the classification hierarchy). SCI Quad – Old Injury XE "SCI Quad – Old Injury" (Class #47 in the Patient Classification hierarchy)Patient Class Overview:The SCI Quadriplegia (Quad) – Old Injury patient class is based on diagnosis criteria obtained from the Patient Treatment File (PTF.) This class includes patients: classified as SCI Quadriplegic - New Injury in a prior year who are not considered institutionalized, and diagnosed with a principal or secondary spinal cord injury ICD-9 code listed below.The SCI Classification Group (including the New SCI/Institutionalized classes and the Old Injury classes) are maintained in the ARC SCI registry that dates back to fiscal year 1988. It is important to note that patients in the SCI classes must have been admitted at least once since 1988 with a Principal or Secondary SCI diagnosis to be included in any of the SCI classes. Patients receiving exclusively outpatient care for the SCI condition without ever having been admitted for the SCI condition are excluded from the SCI patient classesData Sources(s) and Class Criteria:The data source for the SCI Quad – Old Injury patient class is the Patient Treatment File (PTF) N501 transactions. Patients qualify for this patient class if they were part of the SCI - Quad New Injury class in a prior year or have a PTF ICD-9 Principal or Secondary Diagnosis Code of:344.0X — Quadriplegia and quadriparesisSCI –Old Injury patients are “class protected”, which means that an SCI-Old Injury patients will not be placed in a class that is lower on the patient classification hierarchy than the SCI- Old Injury class when s/he presents for treatment in any subsequent year. Note that telephone encounters, secure messaging and pharmacy prescription refills encounters do not qualify as workload that retains a patient in the SCI Old Injury class. Specifically, fiscal year workload that exclusively includes telephone encounters or secure messaging will place the patient in the most appropriate Basic Vested class contingent upon the diagnosis and clinical codes used for the encounter(s). Workload that exclusively includes prescription refills will place the patient in the Pharmacy patient class. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. Criteria Changes to the SCI Quad - Old Injury class for VERA 2013: SCI Old Injury patients that exclusively receive telephone care or secure messaging in a fiscal year are placed in the most appropriate Basic Care patient class based on care received. Exclusively telephone workload or secure messaging does not qualify for this class. In subsequent years when other clinical workload is evident, the patient will be returned to the Old Injury patient class. Care and Price Group: Complex Care group, Price Group #8 - Supportive Care.Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: Permanent Class. The SCI Quad - Old Injury class is a permanent class. SCI Quad - Old Injury patients presenting to the VA for treatment (inpatient or outpatient) in subsequent years will be retained in this class unless the patient qualifies for a higher class within the patient classification hierarchy. Stroke XE "Stroke" (Class # 36 in the Patient Classification hierarchy)Patient Class Overview: The Stroke patient class is based on diagnosis criteria obtained from the Patient Treatment File (PTF.) This class includes patients who were compromised by a stroke, as indicated by specific ICD-9 diagnosis codes listed below. The Stroke patient class is a three-year class. Data Sources(s) and Class Criteria:The data source for the Stroke patient class is the PTF N501 transactions. A patient is included in the Stroke patient class in either of the two ways listed below. Note that “X” in the code extension allows for any numeric digit in its place. 1. A principal diagnosis of Stroke, CVA or Occlusion (430 - 436): 430.XXSubarachnoid Hemorrhage 431.XXIntracerebral Hemorrhage432.XXOther and unspecified Intracranial Hemorrhage433.XXOcclusion and Stenosis of Precerebral Arteries434.XXOcclusion of Cerebral Arteries435.XXTransient Cerebral Ischemia436.XXAcute, but ill-defined, Cerebrovascular Disease997.02Iatrogenic cerebrovascular infarction or hemorrhage Followed by one of the following conditions:784.3Aphasia 784.51Dysarthria (effective 10/1/09) 784.59Other speech disturbance (replaced 784.5 effective 10/1/09)787.2X Dysphagia342.0X - 342.9XHemiplegia and Hemiparesis344.0* - 344.9Quadriplegia and Quadriparesis*Note: ICD-9 codes 344.0X or 344.1X will result in the patient being placed in a Spinal Cord Injury (SCI)-Old Injury patient class.OR2. A principal (or secondary) diagnosis of 438.XX (Late effects of cerebrovascular disease), excluding the following ICD-9 diagnosis codes: 438.0Cognitive deficits438.83 Facial weakness438.10 Speech and language deficits, unspecified438.85 Vertigo438.19 Other speech and language deficits438.89 Other late effects of cerebrovascular diseaseAlterations of sensationsDisturbances of vision438.9 Unspecified late effects of cerebrovascular diseaseNon-VA or Contracted Care: A non-VA PTF is required for the Stroke class in the first/initial year as it provides a principal and up to four secondary diagnosis codes. The Fee Payment Files may not contain secondary diagnosis codes but are used as a data source for the costs of the non-VA care. Criteria Changes to the Stroke Patient class for VERA 2013: In the two immediate years following Stroke classification, patients that are “class protected” must receive clinic care other than telephone encounters, secure messaging and pharmacy refills to be retained in the Stroke patient class. Patients in the Stroke patients that exclusively receive telephone care or secure messaging in a fiscal year are placed in the most appropriate Basic Vested Care patient class based on care received. In either of the two subsequent years when other clinical workload is evident, the patient will be returned to the Stroke patient class. Care Group and Price Group: Complex Care group, Price Group # 7 – Specialized Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are VERA-funded. Classification Timeframe: Three-year class protection. A patient classified as Stroke is “class protected” for the two immediate subsequent classification years, meaning that the patient will not be placed in a class lower on the classification hierarchy than the Stroke patient class if s/he receives VHA health care services in either of the two immediate succeeding years. Class protection does not, however, preclude the Stroke patient from moving to a class that is higher on the classification hierarchy. The class protection status restarts each time the patient is admitted with qualifying diagnosis codes for the Stroke patient class. The class protection is intended to encourage outpatient treatment whenever possible for the treatment of Stroke-related conditions. Substance Abuse XE "Substance Abuse" (Class #48 in the Patient Classification hierarchy)Patient Class Overview:The Substance Abuse patient class is based on utilization and diagnosis criteria. Patients in this class must have at least 180 BDOC in an inpatient setting and a specific principal diagnosis from the list below. Patients in this class need substantial inpatient care for the treatment of their substance abuse problems, which are usually associated with dementia. Patients requiring outpatient treatment for substance abuse are typically classified into the Addictive Disorders Basic Care patient class. Data Sources(s) and Class Criteria:The data source for the Substance Abuse patient class is the Patient Treatment File (PTF) N501 transactions. Inclusion in the Substance Abuse patient class requires at least 180 BDOC as an inpatient and a principal diagnosis from the following list:ICD-9Description291.XXAlcoholic Psychoses292.XXDrug Psychoses303.XXAlcohol Dependence Syndrome304.XXDrug Dependence305.XXNondependent Abuse of DrugsThe bed days of care (BDOC) required to qualify for this patient class do not need to be consecutive days, since the annual fiscal year total is used (including regular BDOC, census BDOC, transfer BDOC and the excluded pass and ABO days). BDOC are computed by counting the total bed days associated with the entire length of stay (LOS), even when the admission date occurred in a prior fiscal year. For example, all BDOC associated with a LOS that began in a prior fiscal year will be counted towards the 180 BDOC requirement. If the patient has a primary diagnosis of Alzheimer’s Disease a secondary diagnosis from above will place the patient in the Schizophrenia/Dementia patient class. Substance Abuse is a class in the CMI group, which started with the PTF data in FY89. Unlike patients in other CMI patient classes, patients in the Substance Abuse patient class must meet the criteria each fiscal year. Non-VA or Contracted Care: The Fee Payment Files are the data source for this patient class. However, non-VA hospitalizations that are paid for by the VA should be recorded in a non-VA PTF, which allows for a principal and four secondary diagnosis codes. If a patient has a principal diagnosis of Alzheimer’s disease, secondary diagnosis codes will be screened for a CMI diagnosis code. Criteria Changes to the Substance Abuse Patient Class since VERA 2013: There were no changes made to the Substance Abuse class criteria. Care Group and Price Group: Complex Care group, Price Group #9 - Chronic Mental Illness. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are funded in VERA. Classification TimeframeAnnual Class. Patients must meet the Substance Abuse classification criteria each year to remain in this patient class. Transplant XE "Transplant" (Class # 56 in the Patient Classification hierarchy)Patient Class Overview:The Transplant patient class is based on ICD-9 procedure coding criterion that identifies a specific transplant procedure. This class includes patients who receive a transplant that is appropriately documented in a Patient Treatment File (PTF). Patients receiving contracted or non-VA transplants that are paid for by the VA are also included in this class provided the procedure is accurately documented in the Patient Treatment File (PTF).This class includes patients that have received a VHA sponsored transplant (including a transplant performed by, or paid for by the VHA and documented in a non-VA PTF) in the fiscal year. In subsequent classification years, post-organ transplant patients will fall no lower on the classification hierarchy than the History of Transplant patient class when the patient has an appropriate post-transplant code (V42.XX) and receives anti-rejection medication from the VHA that is documented in the Pharmacy Benefits Management (PBM) package. (See paragraph D below for details on organ and bone marrow transplants in subsequent years.) Data Sources(s) and Class Criteria:The Transplant patient class is based on ICD-9 Procedures codes located in the Patient Treatment File (PTF). These codes are located in two places within the PTF as follows: ICD-9 Surgical Procedure Codes (Operating Room Procedures) are located in the PTF N401 transaction.ICD-9 Procedure Codes (Non-Operating Room Procedures) are located in the PTF N601 transactions CodeNameCodeName37.51Heart Transplantation 41.05Allogeneic Hematopoietic Stem Cell Transplant33.5 Lung Transplantation41.06Cord Blood Stem Cell Transplant33.51Unilateral Lung Transplant41.07Autologous Hematopoietic Stem Cell Transplant with Purging33.52 Bilateral Lung Transplant41.08Allogenic Hematopoietic Stem Cell Transplant with Purging33.6Combined Heart/Lung Transplant41.09Autologous Bone Marrow Transplant with Purging41 Bone Marrow Transplant50.51Auxiliary Liver Transplant 41.01Autologous Bone Marrow Transplant50.59Liver Transplantation41.02Allogeneic Bone Marrow Transplant with Purging55.61Renal Autotransplantation41.03Allogeneic Bone Marrow Transplant without Purging55.69Other Kidney Transplant41.04Autologous Hematopoietic Stem Cell Transplant99.79Other Therapeutic Apheresis*Note that in subsequent years, transplant patients that receive anti-rejection drugs from the VHA qualify for the Basic Care History of Transplant class. The qualifying transplant codes include: V42.0 Kidney replaced by transplantV42.1??? Heart replaced by transplantV42.6??? Lung replaced by transplant V42.7??? Liver replaced by transplant V42.83? Pancreas replaced by transplant In addition, patients with a VHA provided or sponsored bone marrow transplant will be placed in the History of Transplant class for the immediate five years following the transplant. Non-VA or Contracted Care: All Non-VA transplants that are paid for by the VA must be recorded in the PTF as it provides the precise procedure code(s) for this patient class. Note: patients whose transplants were not performed by or paid for by the VHA are not included the Transplant class. Criteria Changes to the Transplant patient class for VERA 2013: No changes. Care Group and Price Group: Complex Care group, Price Group # 10 - Critically Ill. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are funded in VERA. Classification Timeframe: One-year patient class. Traumatic Brain Injury XE "Traumatic Brain Injury" (Class # 39 in the Patient Classification hierarchy)Patient Class Overview: The Traumatic Brain Injury (TBI) patient class is based on diagnosis criteria obtained from the Patient Treatment File (PTF.) This class includes patients who are diagnosed with a traumatic brain injury as indicated by the specific ICD-9 diagnosis codes listed below. Patients are retained in the TBI class when they present for care in the two subsequent years following an admission with a TBI diagnosis code. This class also includes patients that had previously been classified as Polytrauma for up to three years subsequent to the Polytrauma classification. Data Sources(s) and Class Criteria: Initial classification for the TBI patient class requires an inpatient stay where the PTF N501section indicates the following inpatient diagnosis codes in one of two ways:1. An inpatient admission with a TBI principal diagnosis from the following list: ICD-9 CodesDescription800.XXFracture of vault of skull801.XXFracture of base of skull803.XXOther / unqualified skull fractures804.XXMultiple fractures involving skull or face with other bones851.XXCerebral lacerations and contusion852.XXSubarachnoid, subdural, and extradural hemorrhage, following injury853.XXOther and unspecified intracranial hemorrhage following injury854.XXIntracranial injury of other/unspecified natureORAn inpatient admission with a V57.XX (Rehab. procedures) and TBI secondary diagnosis code of: ICD-9 CodesDescription800.XXFracture of vault of skull801.XXFracture of base of skull803.XXOther / unqualified skull fractures804.XXMultiple fractures involving skull or face with other bones851.XXCerebral lacerations and contusion852.XXSubarachnoid, subdural, and extradural hemorrhage, following injury853.XXOther and unspecified intracranial hemorrhage following injury854.XXIntracranial injury of other/unspecified nature310.2Post-Concussion syndrome905.0Late effect of fracture of skull and face bones907.0Late effect of intracranial injury without mention of skull fractureNon-VA or Contracted Care: Non-VA hospitalizations for TBI that are paid for by the VA must be recorded in a non-VA PTF, which allows for a principal and up to four secondary diagnosis codes. Purchased TBI workload recorded in the fee payment files alone (without a corresponding non-VA PTF) will not be included in this patient class for the initial qualifying year. Cost data from the Fee files will be attributed to the patient. Criteria Changes to the TBI patient class for VERA 2013: In the two or three immediate years following TBI or Polytrauma class, respectively, patients that are “class protected” must receive clinic care other than telephone encounters, secure messaging and pharmacy refills to be retained in the TBI patient class. Patients in the TBI class that exclusively receive telephone care or secure messaging in a fiscal year are placed in the most appropriate Basic Vested Care patient class based on care received. In the remaining subsequent years when other clinical workload is evident, the patient will be returned to the TBI/PT patient class. Care Group and Price Group: Complex Care group, Price Group #7 - Specialized Care. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are funded in VERA. Classification Timeframe: Three-year class. In addition to the classification year, a TBI patient is class-protected for the immediate two subsequent fiscal years (three years for post-Polytrauma patients) if the patient receives VHA healthcare services other than telephone encounters, secure messaging and prescription refills. Class protection status ensures that these patients fall no lower than the TBI class if they present for treatment in the protected subsequent years. Class-protected TBI patients may qualify for a higher patient class if additional criteria are met. In addition, each time the patient presents for inpatient treatment with a TBI qualifying diagnosis, the class protection status is re-set, allowing for additional years of class protection. The class protection is intended to encourage outpatient treatment whenever possible for the treatment of TBI-related conditions. Ventilator Dependent XE "Ventilator Dependent" (Class # 59 in the Patient Classification hierarchy)Patient Class Overview: The Ventilator Dependent patient class relies on two data sources to identify patients that are ventilator dependent for at least 31 BDOC during the fiscal year. Ventilator Dependent patients are identified by the PTF, which is the data source for both the clinical code of Continuous Mechanical Ventilation for 96 consecutive hours and a minimum of 31 bed days of care (BDOC). Data Sources(s) and Class Criteria:The data sources used for the Ventilator Dependent patient class include:PTFs for all admissions, bed transfers and census BDOC are reviewed for the cumulative total of 31 BDOC where the ICD-9 Procedure Code 96.72, “Continuous Mechanical Ventilation for 96 consecutive hours or more” is documented. The procedure code is documented in the PTF in the N401 section for operating room procedures or the N601 section for non-operating room procedures. Total BDOC are counted for each treating specialty where code 96.72 was entered. If the patient is transferred to another treating specialty, the Ventilator procedure code must be re-coded into the PTF at the new treating specialty indicating that the patient continues to receive continuous mechanical ventilation. Non-VA or Contracted Care: Non-VA hospitalizations that are paid for by the VA must be documented in a non-VA PTF that documents the ICD-9 procedure code 96.72. Thirty-one BDOC and the 96.72 code are required in the non-VA bed setting. Criteria changes to the Ventilator Dependent class for VERA 2013: No changes were made to the Ventilator Dependent classification criteria. Care Group and Price Group: Complex Care group, Price Group # 10 - Critically Ill. Eligibility for VERA funding: The VERA 10 prices were computed for two groups of patients: Enrollment Priority Groups 1-6 and Priority Groups 7 & 8. All Complex care patients with the exception of those covered by Sharing Agreements or TRICARE are funded in VERA. Classification Timeframe: Annual. A patient must meet the Ventilator Dependent classification criteria each year. ................
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