advanced care planning · total beneficiaries cost national benchmark practice total 381 $10,518...
TRANSCRIPT
Advanced Care Planning
MACRA
ALEC M. ANDERS, MD
FAMILY MEDICINE PRACTITIONER
Who Can Perform ACP Services
oPhysicians
oNon Physician Practitioners whose scope of practice includes independent CMS billing and the delivery of Advanced Care Planning services
Talking to the Patient
Who starts the conversation?
•Patient can initiate conversation
•Physician can initiate when there has been a change in status or a transition in care
•Advance care planning is voluntary, patient’s discretion
•Face-to-face only; no telemedicine
•Patient must be present unless he or she lacks capacity
Conversation Points
What do practitioners talk about?
◦ Quality of life expectations through transitions in health
◦ Patient’s preferences for treatment and options for achieving
goals
◦ Advance care planning tools – e.g., living wills, health care proxies, and more
◦ Advance care planning forms
What Diagnosis Must be Used?
oThe condition for which you are counseling the beneficiary regarding the Advance Directives discussion
Advanced Care Planning
CPT codes 99497 and 99498
NIHARIKA KHANNA, MBBS,MD,DGO
ASSOCIATE PROFESSOR FAMILY AND COMMUNITY MEDICINE
DIRECTOR MARYLAND LEARNING COLLABORATIVE
Medicare Part B effective Jan 1, 2016
oCPT code 99497 for Advanced Care Planning (ACP) billed when services are provided as a part of the Annual Wellness Visit
oPlus CPT code 99498 for any additional 30 minutes needed
oIn addition to Annual Wellness Visit codes G0438 and G0439
oWhen ACP services are offered as part of Annual Wellness Visit, the coinsurance and deductible are not applied for ACP (Once per year)
oModifier 33 (Preventive Services) is to be used when ACP and Annual Wellness Visit is billed together
oACP and Annual Wellness Visit must be billed together on the same claim
Medicare Part B effective Jan 1, 2016
Why are there two codes?
◦ 99497 applies to the first 30 minutes of an advance care planning discussion
◦ 99498 applies to each additional 30 minutes (in conjunction with 99497)
◦ Codes do not exclude other members of a practice from taking part
◦ Billing practitioner must “manage, participate and meaningfully contribute to the provision of these services”
Billing CPT codes 99497 and 99498 Frequency
oThere are no limits to the number of times Advanced Care Planning billing codes can be used
oThe CMS expects that each time bills are dropped, the beneficiary health status and wishes regarding his/her end of life care is discussed
o99497 and 99498 can be billed with most other E/M codes on the same day
o99497 and 99498 can be billed with Transition of Care Management (TCM) and Chronic Care Management (CCM) codes and within global surgical periods
In What Settings can Advanced Care Planning Codes 99487 and 99498 be Used?
oThere are no place of service limitations on ACP billing codes
oACP codes maybe billed depending on the needs and conditions of the beneficiary
oThe ACP codes can be billed by physicians/practitioners in both inpatient and hospital settings
Advanced Care Planning Service Delivery Documentation
oDiscussion with the beneficiary, or family members and/or surrogate
oVoluntary nature of the encounter
oExplanation of the Advanced Directives
oCompletion of Advanced Directives forms and scanning into the chart
oWho was present at the encounter
oTime spent in face-to-face encounter
oCompletion of the Advanced Directive is not a requirement for billing the service
What if I can’t Answer All My Patient’s Questions?
◦CMS.gov◦National Hospice and Palliative Care Organization◦American Academy of Hospice and Palliative Medicine
◦End of Life Care Program◦Compassion and Support at the End of Life
References
ACP for PCP’s : National Hospice and Palliative Care Organization
MLN Matters Number : MM9271 Advanced Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)
CMS FAQs
What is MACRA?Medicare Access and CHIP Reauthorization Act (MACRA)
Replaced the Sustainable Growth Rate (SGR) in 2015
Increases focus on quality and value of care delivered
Provides incentives for clinicians to improve their practices and the quality of care they provide
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
QPPQuality Payment Program (QPP)
The program through which clinicians demonstrate improvements to their practices or quality of care provided
Began in 2017
Provides tools and resources to clinicians who participate in Medicare Part B
Offers an incentive or a performance-based adjustment to participating providers
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
Options for Participating
MIPS adjustments
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
MIPS adjustments
5% lump sum bonus
Not in APM In APM In Advanced APM
+APM-specific rewards
APM-specific rewards
+If you are a Qualifying APM
Participant (QP) =
Year 2 (2018)
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
Quality CostImprovement
Activities
50% 10% 15%
25%
AdvancingCare
Information
The MIPS Final Score is compared to the MIPS performance threshold to determine if you
receive a positive, negative, or neutral payment adjustment.
Change: Performance Category Weights
MIPS Year 2 (2018) Timeline
2018
Performance
period
Feedback
available
Submit
Data
March 31,
2019
Payment
adjustment
January 1,
2020
Increase to minimum performance periods
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
12 months (New)
◦ Quality performance category
◦ Cost performance category
90 days (No Change)
◦ Improvement Activities performance category
◦ Advancing Care Information performance category
Change: Low-Volume Threshold
MIPS eligible clinicians billing more than $90,000 a year in Medicare Part B allowed charges
AND
providing care for more than 200 Medicare patients a year.
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
5 Steps to Avoid a Penalty in 20191. Understand what is at stake for your practice with the implementation of
MACRA and the QPP
2. Determine if your practice is exempt from MIPS or if your practice could tolerate extra risk under an Advanced APM
3. Understand the requirements of each payment model and determine which model will work best for your practice – MIPS and APMs
4. Make a plan to begin collecting data and join an APM or Advanced APM if you have decided to implement one of those models
5. Begin collecting data to report by March 31, 2019
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
MACRA Awareness and Support (MAS)Goal is to assist stakeholders subject to MACRA, such as ambulatory practices and
hospitals, in adjusting their approach and practice management to comply with MACRA
specifications.
Educates stakeholders on the components of Merritt-based Incentive Payment System
(MIPS) and Advanced Payment Models (APMs).
Practices in Maryland—especially small practices located in rural or underserved areas
and/or not affiliated with a hospital—may benefit from technical and administrative support
to transform practice workflows and optimize the use of health IT.
More resources are available at
http://mhcc.maryland.gov/mhcc/pages/apc/apc/apc_macra.aspx
More Information From CMSQPP Resource Library
https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Resource-library.html
QPP Year 2 Final Rule Fact Sheet
https://www.cms.gov/Medicare/Quality-Payment-Program/resource-library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf
QPP Year 2 Final Rule Executive Summary https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/QPP-Year-2-Executive-Summary.pdf
MHCCM A R Y L A N D
HEALTH CARE
COMMISSION
Practice: John Doe, MD
Tax Identification Number: 123456789
Enrollment Date: 12/12/16
Quality and Resource Use
Report (QRUR) 2016
Total Beneficiaries
Cost National
Benchmark
Practice Total 381 $10,518 $12,380 Diabetes 163 $15,583 $18,420
COPD 33 $25,358 $29,613
IHD 34 $24,524 $22,117 CHF 34 $29,641 $33,953
Readmissions Rate
58 15.36% 15.29%
Total Cost Difference 2015 to
2016 QRUR:-$99.86
2016 QRUR Average Risk Score 69th Percentile
Current Phase in Practice
TransformationPhase 4
Patient and Family Engagement
Key Performance Indicators Practice Transformation Progress
0%
20%
40%
60%
80%
Performance % National Benchmark
Active e-tool NO Health Literacy Survey NO
Shared Decision Making YES Medication Management YES
Patient Activation NO Support for Patient & Family Voices
YES