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CODING AND REIMBURSEMENT CHANGES Indiana Osteopathic Association 33rd Annual Winter Update December 7, 2014.

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Presentation on theme: "CODING AND REIMBURSEMENT CHANGES Indiana Osteopathic Association 33rd Annual Winter Update December 7, 2014."— Presentation transcript:

1 CODING AND REIMBURSEMENT CHANGES Indiana Osteopathic Association 33rd Annual Winter Update December 7, 2014

2 Presented by Joy Newby, LPN, CPC Newby Consulting, Inc Park Plaza Court Indianapolis, IN Voice: Fax:

3 This presentation was current at the time it was published and is intended to provide useful information in regard to the subject matter covered. Newby Consulting, Inc. believes the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the presentation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed. The information contained in this presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Any five-digit numeric Physician's Current Procedural Terminology, Fourth Edition (CPT) codes, service descriptions, instructions, modifiers, and/or guidelines are copyright 2014 (or such other date of publication of CPT as defined in the federal copyright laws) American Medical Association. For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes and service/procedure descriptions to be used in this presentation. The American Medical Association assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this publication.

4 ICD-10 Update Implementation date remains 10/1/2015 Current Congressional Discussions to delay until 2017 CPT Copyright 2014 American Medical Association 4

5 New Medicare Covered Benefit Chronic care management (CCM) Physicians participating in one of the following CMS models/demonstration programs cannot bill chronic care management (CCM) services for Medicare beneficiaries participating in the program; however, when appropriate, the practice can bill CCM services provided to Medicare beneficiaries who chose not to participate in the program Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration Comprehensive Primary Care (CPC) Initiative CPT Copyright 2014 American Medical Association 5

6 CCM References Federal Register 11/13/2014 – Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015 Final Rule Federal Register 12/10/2013 – Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014 – Final Rule American Medical Association’s CPT and RBRVS 2015 Annual Symposium – 11/19/2014 – Presentation by Kathy Bryant, Director, Division of Practitioner Services, CMS 2015 CPT – Copyright American Medical Association CPT Copyright 2014 American Medical Association 6

7 Chronic Care Management Care management services are management and support services provided by clinical staff, under the direction of a physician or other qualified health care professional to a patient residing at home or in a domiciliary, rest home, or assisted living facility. Does not include Nursing Facilities Physician/Qualified Healthcare Professional will be referred to as provider from this point forward CPT Copyright 2014 American Medical Association 7

8 Chronic Care Management Cont’d Services include establishing, implementing, revising or monitoring the care plan, coordination the care of other professionals and agencies, and educating the patient or caregiver about the patient’s condition, care plan, and prognosis Provider is responsible for managing the care plan Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments CPT Copyright 2014 American Medical Association 8

9 Beneficiary Eligibility Beneficiary must have two (2) or more chronic problems Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline Expected to last more than one year or until the death of the patient CPT Copyright 2014 American Medical Association 9

10 2 or More Chronic Problems Cont’d In 2012, the most common chronic conditions among Medicare beneficiaries were: High blood pressure (58%) High cholesterol (45%) Heart disease (31%) Arthritis (29%) Diabetes (28%) CMS determined that patients with these multiple chronic conditions are at increased risk for hospitalizations, use of post-acute care services, and emergency department visits CPT Copyright 2014 American Medical Association 10

11 Certified EHR Required In order to report and be paid for CCM services, the practice must be using a certified EHR meeting meaningful use criteria for the previous year: if the practice adopted a certified EHR and attested for the incentive payment in 2013, on December 31, 2014, Stage 1 meaningful use criteria are applicable if the practice adopted and attested for the incentive payment in 2011, on December 31, 2014 Stage 2 meaningful use criteria are applicable. CPT Copyright 2014 American Medical Association 11

12 Access Requirements Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments Patient access must be available 24 hours a day, 7 days a week The beneficiary must be provided with a means to make timely contact with health care providers in the practice whenever necessary to address chronic care needs regardless of the time of day or day of the week. This includes enhanced opportunities for a patient to communicate with the provider regarding their care through not only the telephone but also through the use of asynchronous communication through secure , text and other modalities to support access to health care CPT Copyright 2014 American Medical Association 12

13 Access Requirements Cont’d The patient’s initial contact can be with clinical staff employed by the practice (for example, a nurse) and not necessarily with a provider Clinical staff can be any individual who is acting under the supervision of a provider, regardless of whether the individual is an employee, leased employee, or independent contractor of the provider and meets any applicable requirements to provide the services, including licensure, imposed by the State in which the services are being furnished (42 CFR §410.26) CPT Copyright 2014 American Medical Association 13

14 Access Requirements Cont’d Due to the requirement of 24/7 patient access, CMS created a narrow exception to the direct supervision requirement (new exception also applies to transitional care management). CCM requires general supervision General supervision means that the provider does not have to be physically present when the services are performed; however, the services must be performed under the physician’s overall supervision and control. CPT Copyright 2014 American Medical Association 14

15 Access Requirements Cont’d All other incident to requirements are applicable. The clinical staff’s service must be furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment CMS believes that contact will be maintained between the clinical staff person and the physician. For example, the employed clinical staff person will contact the provider directly if warranted and the provider retains professional responsibility for the service CPT Copyright 2014 American Medical Association 15

16 Access Requirements Cont’d Members of the chronic care team who are involved in the after-hours care of a patient must have access to the patient’s full electronic medical record even when the office is closed so they can continue to participate in care decisions with the patient The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) upon whose professional service the incident to service is based CMS has also changed the supervision requirements for the non-face-to-face services included in transitional care management (TCM) to general supervision CPT Copyright 2014 American Medical Association 16

17 Written Protocols The practice must be able to demonstrate the use of written protocols by staff participating in the furnishing of CCM services that describe: The methods and expected ‘‘norms’’ for furnishing each component of chronic care management services furnished by the practice The strategies for systematically furnishing health risk assessments to identify all beneficiaries eligible and who may be willing to participate in the chronic care management services The procedures for informing eligible beneficiaries about chronic care management services and obtaining their consent CPT Copyright 2014 American Medical Association 17

18 Written Protocols Cont’d The steps for monitoring the medical, functional and social needs of all beneficiaries receiving chronic care management services System based approaches to ensure timely furnishing of all recommended preventive care services to beneficiaries CMS recommends, but does not require, the provider to perform the Welcome to Medicare Visit and/or the Annual Wellness Visits Guidelines for communicating common and anticipated clinical and non-clinical issues to beneficiaries CPT Copyright 2014 American Medical Association 18

19 Written Protocol Cont’d Care plans for beneficiaries post-discharge from an emergency department or other institutional health care setting, to assist beneficiaries with follow up visits with clinical and other suppliers or providers, and in managing any changes in their medications Cannot report CCM and transitional care management (TCM) services in the same month When applicable select one or the other 2015 fee schedules CCM (99490) $40.53 TCM (99495)$ CPT Copyright 2014 American Medical Association 19

20 Written Protocols Cont’d A systematic approach to communicate and electronically exchange clinical information with and coordinate care among all service providers involved in the ongoing care of a beneficiary receiving chronic care management services A systematic approach for linking the practice and a beneficiary receiving chronic care management services with long-term services and supports including home and community-based services CPT Copyright 2014 American Medical Association 20

21 Written Protocols Cont’d A systematic approach to the care management of vulnerable beneficiary populations such as racial and ethnic minorities and people with disabilities Patient education to assist the beneficiary to self- manage a chronic condition that is considered one of his/her chronic conditions These protocols must be reviewed and updated as is appropriate based on the best available clinical information at least annually CPT Copyright 2014 American Medical Association 21

22 CCM Provider Requirements - Summary Must be using a qualified EHR and must meet the required meaningful use stage based on when the practice first attested Must develop a process for patients contacting the practice 24/7 Can be clinical staff with an employment relationship with the practice An answering service does NOT meet this requirement Must include telephone, secure messaging (eg, , text), and other modalities Must develop written protocols CPT Copyright 2014 American Medical Association 22

23 Inform the Beneficiary Provider furnishing ongoing care for a beneficiary must inform beneficiary about the availability of the services from the provider and obtain his or her written agreement to have the services provided. Explain what chronic care management services are how these services are accessed if the beneficiary participates in CCM, he/she agrees that only one provider can bill for CCM services how the patient’s information will be shared among other providers in the care team CPT Copyright 2014 American Medical Association 23

24 Initial Discussion of CCM Cont’d Explain that CCM includes electronic communication of the patient’s information with other treating providers as part of care coordination Explain that cost-sharing applies to these services even when they are not delivered face-to-face in the practice a likely benefit of agreeing to receive CCM services is that CCM services may help them avoid the need for more costly face-to-face services that entail greater cost-sharing CPT Copyright 2014 American Medical Association 24

25 Initial Discussion of CCM Cont’d Explain that the agreement for chronic care management services can be revoked by the beneficiary at any time Revocation becomes effective on the first day of the following month the revocation was given Revocation must be documented in the patient's medical record CPT Copyright 2014 American Medical Association 25

26 Documentation of Initial CCM Discussion Document in the patient’s medical record whether the patient agrees to or does not want to participate in CCM Execute a written agreement for those wishing to participate Original to patient’s medical record Copy to patient CPT Copyright 2014 American Medical Association 26

27 Develop a Written Care Plan The care plan is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment, and an inventory of resources and supports Care plan must be established by the patient’s physician or other qualified healthcare professional Provider must use a template in the medical record that is standardized within the practice CPT Copyright 2014 American Medical Association 27

28 Develop a Written Care Plan Cont’d A written or electronic copy of the care plan must be given to the beneficiary and the provision of the plan to the patient must also be recorded in the beneficiary’s electronic medical record For 2015, the practice can use any electronic tool (other than fax) to create the care plan; make the care plan available 24/7 within the billing practice; share the care plan with other providers; and transmit clinical summaries in managing care transitions CPT Copyright 2014 American Medical Association 28

29 Comprehensive Plan of Care Typically includes, but is not limited to: problem list expected outcome and prognosis measurable treatment goals symptom management planned interventions medication management CPT Copyright 2014 American Medical Association 29

30 Comprehensive Plan of Care Cont’d community/social services ordered how the services of agencies and specialists unconnected to the billing practice will be directed/coordinated identify the individuals responsible for each intervention requirements for periodic review and, when applicable, revision of the care plan Part of the plan is based on the stored information in the patient's EHR. Process for updating the care plan when changes to the stored information CPT Copyright 2014 American Medical Association 30

31 Reporting Requirements Reporting is based on clinical staff time – must be at least 20 minutes or more per calendar month Not a per beneficiary / per month payment When requirements are met during the month, CCM is reported on the last day of the calendar month Report CPT code CPT Copyright 2014 American Medical Association 31

32 Clinical Staff Services When appropriate, care coordination activities performed by clinical staff include, but are not limited, to the following: communication and engagement with patient, family members, guardian or caretaker, surrogate decision makers, and/or other professionals regarding aspects of care communication with home health agencies and other community services utilized by the patient collection of health outcomes data and registry documentation ; CPT Copyright 2014 American Medical Association 32

33 Clinical Staff Services Cont’d patient and/or family/caretaker education to support self-management, independent living, and activities of daily living; assessment and support for treatment regimen adherence and medication management; identification of available community and health resources; facilitating access to care and services needed by the patient and/or family; CPT Copyright 2014 American Medical Association 33

34 Clinical Staff Services Cont’d management of transition not reported as part of transitional care management (99495 and 99496) ongoing review of patient status, including review of laboratory and other studies not reported as part of an E/M service Time spent by a clinical staff employee providing aspects of these services to address a patient’s chronic care need outside of the practice’s normal business hours can also be counted towards the time requirement CPT Copyright 2014 American Medical Association 34

35 CCM and Face-to-Face Service Payment for CCM does not include a face-to-face component. Providers separately report any evaluation and management (E/M) service using the code for the appropriate level of care to describe any face-to-face encounter that occurs during the calendar month You cannot count the clinical staff’s time related to the face-to-face E/M when determining whether at least 20 minutes of CCM was provided to the Medicare beneficiary CPT Copyright 2014 American Medical Association 35

36 CCM Coding Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following elements: multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored CPT Copyright 2014 American Medical Association 36

37 CCM Coding Cont’d Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately Diagnosis code(s) reflects the problem(s) related to the clinical staff’s activity CPT Copyright 2014 American Medical Association 37

38 Complex Chronic Care Management Codes These codes are bundled and not separately billable to Medicare or a Medicare beneficiary Complex chronic care management services, with the following requirements: multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; establishment or significant revision of a comprehensive care plan moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not separately reported CPT Copyright 2014 American Medical Association 38

39 Complex Chronic Care Management Codes Cont’d These codes are bundled and not separately billable to Medicare or a Medicare beneficiary each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure [99487] Do not report for care management services of less than 30 minutes additional to the first 60 minutes of complex chronic care management services during a calendar month CPT Copyright 2014 American Medical Association 39

40 New Codes Advanced Care Planning Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional first 30 minutes face-to-face with the patient, family member(s), and/or surrogate 99498each additional 30 minutes (List separately in addition to code for primary procedure) Medicare assigned a “B” status to the following codes meaning the codes are bundled and never paid by Medicare CPT Copyright 2014 American Medical Association 40

41 CPT Surgical Package Definition Updated for 2015 In defining the specific services “included” in a given CPT surgical code, in addition to the operation per se, the following related services are always included when performed by the physician or other qualified health care professional who performs the surgery : E/M service(s) subsequent to the decision for surgery on the day before and/or the day of surgery (including history and physical) Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia CPT Copyright 2014 American Medical Association 41

42 CPT Surgical Package Definition Updated for 2015 Cont’d Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals Writing orders Evaluating the patient in the postanesthesia recovery area Typical postoperative follow-up care CPT Copyright 2014 American Medical Association 42

43 Possible Elimination of Postoperative Days In the Future CMS believes that maintaining the postoperative 10-and 90-day global periods is incompatible with its continued interest in using more objective data in the valuation of Physician Fee Schedule (PFS) services and accurately valuing services relative to each other. As the typical number and level of post-operative visits during global periods may vary greatly across Medicare practitioners and beneficiaries, CMS believes that continued valuation and payment of these face-to-face services as a multi-day package may skew relativity and create unwarranted payment disparities within PFS fee- for-service payment. CPT Copyright 2014 American Medical Association 43

44 Possible Elimination of Postoperative Days In the Future Cont’d In the 2015 Final Rule, CMS proposes to retain global bundles for surgical services, but to refine bundles by transforming over several years all 10- and 90-day global codes to 0-day global codes. Medically reasonable and necessary visits would be billed separately during the pre- and post-operative periods outside of the day of the surgical procedure. CMS is proposing to make this transition for current 10- day global codes in CY 2017 and for the current 90-day global codes in CY 2018 CPT Copyright 2014 American Medical Association 44

45 New and Revised Codes – Joint Injection Previous arthrocentesis, aspiration, and/or injection codes now include “without ultrasound guidance” small joint or bursa intermediate joint or bursa major joint or bursa New arthrocentesis, aspiration, and/or injection codes include “with ultrasound guidance with permanent recording and reporting” small joint or bursa intermediate joint or bursa major joint or bursa CPT Copyright 2014 American Medical Association 45

46 New and Revised Coding Instructions for Rib Fractures To report closed treatment of an uncomplicated rib fracture, use the E/M codes New codes for “open treatment of rib fracture with internal fixation, includes thoracoscopic, visualization when performed, unilateral ribs ribs or more ribs For external rib fixation, use unlisted procedure, neck or thorax CPT Copyright 2014 American Medical Association 46

47 Two Cast/Strapping Codes Deleted Application of turnbuckle jacket, body; only including head CPT Copyright 2014 American Medical Association 47

48 Cardiovascular – Not All Inclusive Significant revisions of existing codes and 4 new codes added in the Pacemaker or Implantable Defibrillator section 2 new codes for trans catheter mitral valve repair, percutaneous approach, including transseptal puncture when performed 25 new codes for extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) services New code – for physician planning of a patient- specific fenestrated visceral aortic endograft requiring a minimum of 90 minutes of physician time CPT Copyright 2014 American Medical Association 48

49 Digestive – Not All Inclusive Significant number of revised codes, new codes, deleted codes, and new/revised parenthetical statements for Esophagoscopy Esophagogastroduodenoscopy Endoscopic Retrograde Cholangiopancreatography (ERCP) Endoscopy, small intestine Endoscopy, Stomal Sigmoidoscopy Colonoscopy CPT Copyright 2014 American Medical Association 49

50 Radiation Oncology Significant number of revised codes, new codes, deleted codes, and new/revised parenthetical statements CPT Copyright 2014 American Medical Association 50

51 Pathology and Laboratory – Not All Inclusive Drug testing subsection has been removed – Deleted CPT codes Drug screen, qualitative; multiple drug classes chromatographic method, each procedure 80101single drug class method (eg, immunoassay, enzyme assay), each drug class 80104multiple drug classes other than chromatographic method, each procedure 80102Drug confirmation, each procedure 80103Tissue preparation for drug analysis CPT Copyright 2014 American Medical Association 51

52 Pathology and Laboratory – Not All Inclusive – Cont’d New Section Titled “Drug Assay” has been added Presumptive Drug Class Screening – 5 new codes Definitive Drug Testing – 59 new codes New codes and description changes in the Therapeutic Drug Assays section Significant number of new and revised codes for Molecular Pathology Procedures CPT Copyright 2014 American Medical Association 52

53 Active Wound Care Management Existing CPT codes for active wound therapy (97605, 97606) now include “utilizing durable medical equipment (DME)” New codes for active wound therapy using disposable non-durable medical equipment (97607, 97608) CPT Copyright 2014 American Medical Association 53

54 Category III CPT Codes Significant number of new, revised, and deleted codes – review to determine whether any affect your specialty CPT Copyright 2014 American Medical Association 54

55 Medicare Fee Schedule for 2015 All Medicare Contractors have published the 2015 fee schedule on their websites Protecting Access to Medicare Act of 2014 (PAMA) provides for a 0.0 percent update for services furnished on or after January 1, 2015, through March 31, 2015 Published Fee schedules are for Dates of Service 1/1/2015 – 3/31/2015 Conversion factor for these dates of service: $ Includes a 0.06 percent reduction from the 2014 conversion factor to offset the estimated increase in Medicare physician expenditures due to the CY 2015 RVU changes CPT Copyright 2014 American Medical Association 55

56 Medicare Fee Schedule for 2015 Cont’d Without Congressional Action, the sustainable growth rate (SGR) calculation will be applied to the current conversion factor, resulting in a decrease of approximately 21.2 percent Conversion factor for dates of service 4/1/2015 – 12/31/2015 is $ CPT Copyright 2014 American Medical Association 56

57 Medicare Deductible for 2015 Deductible Part A – Per Hospitalization $ $1, Part B$ CPT Copyright 2014 American Medical Association 57

58 Thanks for inviting me to your meetings for 23 years It has been a privilege to be a presenter. Happy Holidays! See you in 2015! CPT Copyright 2014 American Medical Association 58


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