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Risk 2.0 with EVE

Downloadable PDF attached.

 

TABLE OF CONTENTS

  

Who is EVE? 

EVE is your virtual team member. EVE (Evidence Validation Engine) is an AI-infused tool that validates your clinical data and uncovers conditions, matching them to ICDs/HCCs. 

 

EVE will:   

  • Validate Member 
  • Validate Admin Encounter 
  • Validate Admin Diagnosis 
  • Suggest Net New Encounter 
  • Suggest Net New Diagnosis 

What is Broad Match? 

When EVE finds evidence for a new Diagnosis, she will provide up to 5 suggested ICDs that best match the evidence. Each suggested code will have a confidence score. 

 

What is a Confidence Score? 

The score indicates the confidence level of the accuracy of the relationship between the evidence on the medical record and the Diagnosis  

 

Benefits 

  • Uses AI to uncover HCC opportunities and accurately capture risk scores  
  • EVE uncovers conditions, matches them to ICD/HCC scores and offers a confidence score to reduce over and under coding  
  • Reduces manual review by automatically validating risk data   
  • Boosts speed and accuracy of coding with an optimized interface that provides coders with more tools to easily find clinical evidence  
  • Provides a highly efficient workflow for health plans to obtain accurate risk data using confidence factors  
  • Cloud-based solution adapts to the needs of distributed workforces while maintaining HIPAA and HITRUST level security.  

 

Feature Overview 

 

Dual Screen Sync 

The ability to code on two monitors at the same time with both screens running in real-time synchronicity. The Document will open in a new browser window. 

 

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Risk 2.0 Page Overview 

  1. Member/Chase Details: Member Name, DOB, Age, Sex, Chase ID, Status, Measure, Review Period. Additional details can be located under the Chase tab 
  2. Count badge: Total pages that contain evidence for the selected card (Member, EncounterDiagnosis) 
  3. Evidence Filters: These filters will display evidence for Member, Encounter, and Diagnosis 
  4. Thumbnail labels: These labels display evidence for the selected card (Member, EncounterDiagnosis) 
  5. Review Tabs: This is where you will code the Member, Encounters, and Diagnosis 
  6. Page Actions: Add Tag, Assign chase, and Pend chase 
  7. Page Navigation: Navigation is hidden by default. Click Main to show navigation / Click Hide to hide navigation 

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Navigation 

  1. Page navigation 
    1. LogoReturns user to Homepage 
    2. Main / Hide: Main will show the Platform navigation. Hide will hide the Platform navigation 
    3. Review: Where coding is performed 
    4. Chase: Additional details about the chase, such as project and address  
    5. Member: All chases associated with that member 
    6. HCC Health Card: The HCC Health Card is an accumulation of all member chases combined within the Project for viewing which HCCs have or have not been substantiated from your claim load file. You can also see any Net New HCC Diagnosis that were not provided on claims. Expand each row to view Diagnosis information 
    7. Comments: This is where you can read and add comments about this Chase. Comments will show Username, Date, Time, and Comment.  
    8. Timeline: This is a complete history of the Chase. It is organized by date, newest to oldest. All timeline entries include the Action taken, User, Date, and Time 
    9. Audit Log:  This is a historical view of what a user has data entered during MRR, OR and OR2 
  2. Page Actions 
    1. Tags: Add or Remove Chase Tags. Click 3-dot icon to access additional tags that are hidden from view 
    2. Assign: Assign / Unassign chase 
    3. Pend: Pend or Update an existing Pend 

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Member / Chase Details 

  1. Arrow to return to My Chases 
  2. Member Details: Name, DOB, Age, Sex 
  3. Chase Details: Chase ID, Status, Measure, Review Period 
  4. See Chase tab for additional chase details 

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Rapid Scan Thumbnails 

A quick way to manage and filter to the pages with evidence that support Member, Encounter and Diagnosis validation 

 

Member Thumbnails 

  1. Count Badge: Total pages that contain Member Evidence 
  2. Thumbnail Filters: Filters to sort to pages that contain Member Name, DOB, Gender 
  3. No EvidenceClick No Evidence to view all pages in the medical record that do not contain member evidence  
  4. Thumbnail labels: Details about the evidence and where it is located on the medical record  

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Encounter Thumbnails 

  1. Count Badge: Total pages that contain Encounter Evidence 
  2. Thumbnail Filters: Filters to sort to pages that contain DOS, and Provider 
  3. No Evidence: Click No Evidence to view all pages in the medical record that do not contain Encounter evidence for that DOS 
  4. Thumbnail labels: Details about the evidence and where it is located on the medical record  

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Diagnosis Thumbnails 

  1. Count Badge: Total pages that contain Diagnosis Evidence 
  2. Thumbnail Filters: Filters to sort to pages that contain Diagnosis, Signs, Symptoms, and Medications 
  3. No Evidence: Click No Evidence to view all pages in the medical record that do not contain Diagnosis evidence for that DOS 
  4. Thumbnail labels: Details about the evidence and where it is located on the medical record  

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Review tabs 

When reviewing a Risk chase, the data entry screen is divided into 3 tabs: Member, Encounter, Submit. 

 

Member Tab 

  1. Member Tab: The member tab is used to validate the member. No other action can take place until the member has been validated. 
  2. Member Validation: Select Yes, to validate the member 
  3. DOB verificationYes is selected by default, update if needed 
  4. Gender verificationYes is selected by default, update if needed 
  5. Next: Once member is validated you can click Next to go to the Encounters tab OR click the Encounter tab  

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Encounter Tab 

  1. Encounter Tab: The Encounter tab is used to validate Encounters and Diagnoses. Chase cannot be submitted until all Admin Encounters and Diagnosis has been reviewed 
  2. Count Badge: Total Encounters to be reviewed 
  3. All Encounters can be accessed from the dropdown. They are categorized: Admin, Coder, EVE 
  4. Encounter Validation: Select Yes, to validate the Encounter 
  5. You cannot review any Diagnosis until the Encounter has been validated 
  6. Admin DiagnosisClicking the Diagnosis card will populate evidence in the medical record to support that DiagnosisIf EVE could validate the Diagnosis, the icon will display green. If EVE could not validate the Diagnosis, the icon will display red. 
  7. EVE DiagnosisClicking the Diagnosis card will populate evidence in the medical record to support a broad match of results.  

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Submit Tab 

Submit tab is your opportunity to review all Encounters and Diagnosis one last time before submission. This tab cannot be accessed until all Admin Encounters and Diagnosis have been reviewed.  

  1. Submit tab displays all Valid and Non-Valid Encounters 
  2. Count Badge: Total Valid Encounters for submission 
  3. Each Encounter will have a brief summary, such as total submittable Diagnosis 
  4. Encounters can be edited by clicking the edit icon. User will be redirected to the Encounter tab. 
  5. Diagnoses can be edited by clicking the edit icon. User will be redirected to the Encounter tab and the selected Diagnosis card will be displayed. 
  6. Submit: When ready, click submit. The next chase in your work queue will automatically load. 

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How to Review a Chart 

 

Step 1: Enable Dual Screen Sync 

  1. Click the screen sync icon to open the MR on a second browser tab 

To return to the default view close browser tab or refresh the page 

Step 2: Verify Member   

  1. The default window will now display Member Validation filters for Member Name, DOB and Gender for review  
  2. Select Yes or No on the Members tab.   
  3. Once validated, click Next to select the Encounter Tab 

- Member is automatically validated if EVE finds evidence for Member Name, DOB, and Gender

Member Name, DOB, and Gender will be highlighted in the medical record if EVE locates evidence 

- When selecting No, choose a Move Back Reason from the dropdown and click Submit and a new chase from your work queue will load.


Step 3: Verify Encounters ADMIN, EVE and CODER (OR1 and OR2)   

  1. Click on Encounters tab, Encounters dropdown will display all Encounters by type:  
  2. ADMIN Encounter – Admin (Claims) EncountersThese Encounters are auto populated.  
    1. Select Yes if Encounter is found in the MR and proceed to review Diagnoses  
    2. Select No if Encounter is not found in the MR and review next Encounter 
  3. EVE Encounter  Coder is not required to review 
    1. Select Yes if Encounter is found in the MR and proceed to review Diagnoses   
    2. If Encounter is not found in the MR or invalid, you can skip or select NoSelecting no will also delete all Diagnoses associated with the Encounter, then select next Encounter.   
  4. CODER Encounter - These are the net new Encounters added by the coder  
    1. Select Yes if Encounter is found in the MR and proceed to add Diagnoses  
    2. If Encounter is not found in the MR or invalid, click trash can icon to delete, you will be prompted to confirm before permanent delete. This will also delete all Diagnoses associated in the Encounter, then select next Encounter.   

- Green EVE icon means EVE has located evidence in the medical record 

- Red EVE icon means EVE could not locate evidence in the medical record 

DOS and Provider will be highlighted on the medical record if EVE locates evidence 

Users are not required to review EVE Encounters 

For any Encounter to be valid, there must be at least 1 valid Diagnosis associated with that Encounter 

In some cases, users may need to add Provider 

Step 4: Verify Diagnoses ADMIN, EVE and CODER  

  1. ADMIN DIAGNOSIS – Admin (Claims) Diagnoses. Coder is required to review and append a VRC to all
  2. ADMIN Diagnoses to submit  
    1. Click on Diagnosis card, review page number, verify provider, and select VRC.   
    2. To close, click on the top of the Diagnosis card or selected another Diagnosis card. 
  3. EVE DIAGNOSIS - Coder is not required to review or append VRC to EVE Diagnosis  
    1. Click on Diagnosis card, if a match in the MR is found, select desired Diagnosis then the fields will auto populate and VRC 00 will be applied (default VRC)  
    2. To close, click on the top of the Diagnosis card or selected another Diagnosis card. 
  4. CODER DIAGNOSIS - Coder added net new Diagnoses. Accessible in OR1 And OR2  
    1. Click on a Diagnosis card, verify page number, provider and VRC, make corrections as appropriate  
    2. To delete a Diagnosis, click on the trash icon on the Diagnosis card, you will be prompted to confirm before permanent delete  

- Green EVE icon means EVE has located evidence in the medical record 

- Red EVE icon means EVE could not locate evidence in the medical record 

- Diagnosis, Signs, Symptoms, and Medications will be highlighted on the medical record if EVE locates evidence 

- Users are not required to review EVE Diagnosis 

- In some cases, users may need to add Provider  

- If provider needs to be changed, click to launch a provider search. Type in name of provider and select one from the results.  

Step 5: Adding a new Encounter or a new Diagnosis  

  1. Click on the yellow plus sign on the bottom right of the screen  
  2. Select Add Encounter or Add Diagnosis  
    1. To add an Encounter, enter page number, date, service type and provider  
    2. To add a Diagnosis, enter page number, date, ICD code and VRC  

To delete a Coder added Encounter or Diagnosis click on the trash icon, you will be prompted to confirm before permanent delete 

Step 6: Submit 

  1. Click on the Submit tab - this will display all Valid and Non-Valid Encounters and Diagnoses for a final review  
  2. Click Submit 

Changes can be made from this tab by clicking on the edit icon next to the Encounter and/or Diagnosis card 


Additional Resources 

 

Scenario 

Outcome 

Member is Valid 

User can now access the Encounters for review 

Member is not valid 

Chase goes to QA 

Admin Encounter is Valid 

User can now review all Diagnosis associated to that Encounter 

Admin Encounter is Not Valid 

User cannot review any Diagnosis associated to that Encounter 

Admin Diagnosis is Valid 

User selected one of the following VRC: 00, 103, or 105Diagnosis is Validated 

Admin Diagnosis is Not Valid 

User selected one of the following VRC: 11, 12, 13, 31, 33, 39, 50, 51, 52, 104, 107, 108, or 109. Diagnosis is Not Valid 

EVE Encounter is Valid 

User can now review all EVE Diagnosis associated to that Encounter 

EVE Encounter is Not Valid 

No action is needed 

EVE Diagnosis is Valid 

VRC 00 is automatically appliedDiagnosis is Validated. 

EVE Diagnosis is Not Valid 

No action is needed 

Coder added Encounter is Valid 

User can now review all Diagnosis associated to that Encounter 

Coder added Encounter is Not Valid 

User deletes Encounter. User cannot review any Diagnosis associated to that Encounter 

Coder added Diagnosis is Valid 

User selected one of the following VRC: 00, 103, or 105. Diagnosis is Validated 

Coder added Diagnosis is Not Valid 

User deletes Diagnosis  

 

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