CurrentColorado Rocky Mountain Health PlansPolicy N/A

Premium Specialty: Cardiology Patient Annual Cost — Cost Inclusion Rules

Defines which patient treatment episode costs are included in UnitedHealth Premium Cardiology patient annual cost calculations and whether inclusion depends on the attributed physician's level of involvement. Applies to the Premium Specialty: Cardiology methodology.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPremium Specialty: Cardiology Patient Annual Cost — Cost Inclusion Rules

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionApply 'Always Include' or 'Include if Involved' rules when determining whether Cardiology episode costs count toward patient annual cost measures; 'Include if Involved' requires the attributed physician to be responsible for at least 50% of costs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2methods for determining cost inclusion

dozensconditions listed with inclusion rules

50%Include if Involved threshold

yesinformational notes present

Cardiology Condition Inclusion Rules

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Cardiology condition inclusion rules (sample entries)

For Premium Specialty: Cardiology, each listed condition is assigned either 'Always Include' or 'Include if Involved' for patient annual cost calculations. Examples follow.

Atrial Fibrillation and Flutter — Always Include

Aortic Aneurysm — Include if Involved

Cardiac Congenital Disorder — Always Include

Cardiac Infection — Always Include

Cardiomyopathy — Always Include

Congestive Heart Failure — Always Include

Ischemic Heart Disease — Always Include

Hypertension — Include if Involved

Pulmonary Heart Disease — Always Include

Varicose Veins of Lower Extremity, Single Side — Include if Involved

Severe Ventricular Rhythms — Always Include

Condition–Code Mapping and Thresholds

Condition inclusion mapping (Cardiology)mixed

Anxiety Disorder or Phobias	Always Include = .; Include if Involved = X
Aortic Aneurysm	Always Include = .; Include if Involved = X
Aortic Aneurysm, with Percutaneous Intervention	Always Include = .; Include if Involved = X
Aortic Aneurysm, with Surgery	Always Include = .; Include if Involved = X
Aortic Aneurysm, with Valve	Always Include = .; Include if Involved = X
Arterial Inflammation	Always Include = .; Include if Involved = X
Arterial Inflammation, with Percutaneous Intervention	Always Include = .; Include if Involved = X
Arterial Inflammation, with Surgery	Always Include = .; Include if Involved = X
Asthma*	Always Include = .; Include if Involved = X
Atrial Fibrillation and Flutter*	Always Include = X; Include if Involved = .

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inv-03: Physician involvement threshold for 'Include if Involved'

Physician involvement threshold>= 50% of episode costs

ContextUsed for 'Include if Involved' determinations of episode cost inclusion

Applies toConditions designated 'Include if Involved' in the Cardiology Premium Specialty mapping

How Inclusion Methods Affect Provider Reporting

Billing Rule

Cost inclusion methods: Always Include vs. Include if Involved

Two methods determine whether episode costs are counted for Premium Specialty: Cardiology. "Always Include": include the episode costs regardless of the attributed physician’s level of involvement. "Include if Involved": include the episode costs only if the attributed physician is responsible for at least 50% of the costs.

Providers should understand which method applies to each condition listed in the Cardiology inclusion rules.
When a condition is marked "Include if Involved," documentation and billing must support that the attributed physician was responsible for >= 50% of episode costs to have costs counted.

Key Definitions

inv-05: Always Include

Always IncludeInclude costs regardless of the attributed physician's level of involvement in treatment of the patient's condition.

Method roleOne of two methods that govern whether episode costs are counted for Cardiology patient annual cost calculations.

When usedApplied to conditions listed as 'Always Include' in the Cardiology condition inclusion mapping.

inv-06: Include if Involved

Include if InvolvedInclude costs only if the attributed physician is responsible for at least 50% of the episode costs.