cpas & advisors · “we propose that a rhc or fqhc can bill for ccm services furnished by, or...
TRANSCRIPT
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experiencemomentum//
CPAs&ADVISORS
KentuckyPrimaryCareAssocia<on:2015FallConference
CHRONICCAREMANAGEMENT–WHATDOESTHISMEANTOYOU?
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2//experiencemomentum
ThefollowinginformaConwasusedasavisualaidduringapresentaCon/trainingsessionledbyaBKD,LLPadvisor.ThiscontentwasnotdesignedtobeuClized
withouttheverbalporConofthepresentaCon.Accordingly,informaConincludedontheseslides,insomecases,areonlyparCallistsofrequirements,recommendaCons,etc.andshouldnotbeconsideredcomprehensive.Thesematerialsarebeingissued
withtheunderstandingtheymustnotbeconsideredlegaladvice.
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Ø ChronicCareManagement(CCM)Services
DefinedØ CMSRulingsØ CCMScopeofServicesElements–
Highlights
Ø CCMCPTCodeBillingRequirementsØ ElectronicHealthRecord(EHR)
Requirements
Ø HealthCenterProviderRevenuePotenCal
3//experiencemomentum
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4//experiencemomentum
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5//experiencemomentum
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CHRONICCAREMANAGEMENTDEFINEDCMSdefinesCCMas:“Chroniccaremanagementservicesfurnishedtopa4entswithmul4ple(twoormore)chroniccondi4onsexpectedtolastatleast12months,orun4lthedeathofthepa4ent,thatplacethepa4entatsignificantriskofdeath,acuteexacerba4on/decompensa4onorfunc4onaldecline.”
6//experiencemomentum
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CHRONICCAREDISEASEOVERVIEW(cont’d)
ChronicDiseaseDefined• Chronicdiseaseisalong-las<ngcondi<onthatcanbecontrolledbutnotcured.
• Condi<onisexpectedtolastatleast12monthsorun<lthedeathofthepa<ent.
• Examplesofchroniccondi<ons:(notallinclusive)Ø Alzheimer’sdiseaseandrelateddemen<a
Ø AsthmaØ CancerØ ChronicObstruc<vePulmonaryDiseaseØ DiabetesØ Heartfailure
7//experiencemomentum
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CMSMEDICAREPHYSICIANFEESCHEDULE
CY2015FINALRULE
• In2014,CMSfinalizedpolicies
toestablishseparatepaymentsforCCMservices
• DidnotincludeFQHCandRHCproviders
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CMSCY2016PROPOSEDRULE
CMSCY2016ProposedRulestates:“Thisproposedruleproposestoprovideanaddi<onalpaymentforthecostsofCCMservicesthatarenotalreadycapturedintheRHCAIRortheFQHCPPSpayment,beginningonJanuary1,2016.ServicesthatarecurrentlybeingfurnishedandpaidundertheRHCAIRorFQHCPPSpaymentmethodologywillnotbeaffectedbytheabilityoftheRHCorFQHCtoreceivepaymentforaddi<onalservicesthatarenotincludedintheRHCAIRorFQHCPPS.”“TherequirementsweareproposingforRHCsandFQHCstoreceivepaymentforCCMservicesareconsistentwiththosefinalizedintheCY2015PFSfinalrulewithcommentperiodforprac<<onersbillingunderthePFSandaresummarizedinTable17.Weproposetoestablishpayment,beginningonJanuary1,2016,forRHCsandFQHCswhofurnishaminimumof20minutesofqualifyingCCMservicesduringacalendarmonthtopa<entswithmul<ple(twoormore)chroniccondi<onsthatareexpectedtolastatleast12monthsorun<lthedeathofthepa<ent,andthatplacethepa<entatsignificantriskofdeath,acuteexacerba<on/decompensa<on,orfunc<onaldecline.”“WeproposethataRHCorFQHCcanbillforCCMservicesfurnishedby,orincidentto,aRHCorFQHCphysician,nurseprac<<oner,physicianassistant,orcer<fiednursemidwifeforaRHCorFQHCpa<entoncepermonth,andthatonlyoneCCMpaymentperbeneficiarypermonthcanbepaid.”
9//experiencemomentum
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CMSCY2016PROPOSEDRULE,CONT.
CMSCY2016ProposedRulestates:“InconsideringCCMpaymentforRHCsandFQHCs,webelievethatthenon-face-to-face<merequiredtocoordinatecareisalsonotcapturedintheRHCAIRortheFQHCPPSpayment,par<cularlyfortheruraland/orlow-incomepopula<onsservedbyRHCsandFQHCs.AllowingseparatepaymentforCCMservicesinRHCsandFQHCsisintendedtoreflecttheaddi<onalresourcesnecessaryfortheuniqueservicesthatarerequiredinordertofurnishCCMservicesthatarenotalreadycapturedintheRHCAIRortheFQHCPPSpayment.“
10//experiencemomentum
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CMSCY2016ProposedRuleSummary• Effec<veJanuary1,2016,intheproposedrule,physiciansbillingunderthePPS
wereeligibletoreceiveseparatepaymentforCCMservices.
• WouldallowRHCsandFQHCstoreceiveseparatepaymentforCCMservices
• ProposedCCMpaymentswouldnotbeincludedin:Ø RHCsall-inclusiverate(AIR)Ø FQHCs’PPS
11//experiencemomentum
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CCMSCOPEOFSERVICECCMservicerequirementsinclude,butarenotlimitedto,thefollowing:• CCMservicesini<a<onduringanannualwellvisit(AWV),Ini<alPreven<ve
PhysicalExam(IPPE)orcomprehensiveE/Mvisit(billedseparately).• Accesstocaremanagementservices24-hour-a-day,7day-aweekaccess.• Con<nuityofcare• CareManagementforchroniccondi<ons• Crea<onofapa<ent-centeredcareplan• Managementofcaretransi<ons• Coordina<onwithhomeandcommunitybasedclinicalserviceproviders• Enhancedcommunica<onopportuni<esforpa<entsand/orcaregivers• Electroncaptureandsharingofcareplaninforma<on
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CCMSCOPEOFSERVICE
• Accesstocaremanagementservices24-hour-a-day,7day-aweekaccess.
Ø Providingpa<entswithameanstomake<melycontactprovidersorclinicalstafftoaddressurgentchroniccareneedsregardlessofthe<meofdayordayoftheweek.
• Con<nuityofcareØ Thepa<entmustbeabletogetsuccessiverou<neappointmentwithdesignatedprovideroramemberofthecareteam.
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CCMSCOPEOFSERVICE
• CareManagementforchroniccondi<onsØ Systema<cassessmentofapa<ent’smedical,func<onal,andpsychosocial
needs,Ø System-basedapproachestoensure<melyreceiptofallrecommended
preven<vecareservices,Ø Medica<onreconcilia<onØ Oversightofpa<entself-managementofmedica<ons.
• Crea<onofapa<ent-centeredcareplan
Ø Basedonaphysical,mental,cogni<ve,psychosocial,func<onal,andenvironmental(re)assessmentandaninventoryofresourcesandsupports.
Ø Itisacomprehensiveplanofcareforallhealthissues.
14//experiencemomentum
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CCMSCOPEOFSERVICE
• Crea<onofapa<ent-centeredcareplan,Ø Ittypicallyincludes,butnotlimitedto:
ü Problemlist
ü Expectedoutcomeandprognosis
ü Measurabletreatmentgoals
ü Symptommanagement
ü Plannedinterven<onsandiden<fica<onoftheindividualsresponsibleforeachinterven<on
ü Medica<onmanagement
ü Community/socialservicesordered
ü Scheduleforperiodicreviewandrevisionofplan(whenapplicable)
15//experiencemomentum
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CCMSCOPEOFSERVICE
• Managementofcaretransi<onsØ Referralstootherclinicians,Ø Follow-upaherapa<entvisittoanemergencydepartment,Ø Follow-upaherapa<entdischargefromahospital,skillednursingfacility,or
otherhealthcarefacility.
• Coordina<onwithhomeandcommunitybasedclinicalserviceprovidersØ Toensureappropriatesupportofapa<ent’spsychosocialneedsandfunc<onal
deficitØ Communica<ontoandfromtheseprovidersmustbedocumentedintheEHR
usingCCMcer<fiedtechnology
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CCMSCOPEOFSERVICE
• Enhancedcommunica<onopportuni<esforpa<entsand/orcaregiversØ Communica<onwiththeprac<<onerregardingthebeneficiary’scarethrough
telephone,securemessaging,secureinternetorotherasynchronousnonface-to-faceconsulta<onmethods(subjecttoHIPAA)
• Electroniccaptureandsharingofcareplaninforma<onØ Availableona24/7basistoallproviderswithintheprac<cewhoarefurnishing
CCMservicesandwhose<mecountstowardthe<merequirementforbillingtheCCMcode.
Ø Sharedelectronically(otherthanbyfacsimile)asappropriatewithotherproviderswhoarefurnishingcaretothebeneficiary.
Ø Mustprovidethepa<entawrijenorelectroniccopyofthecareplanandtodocumentintheEHRthatthiswasdone.
17//experiencemomentum
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ELIGIBLEBENEFICIARY
AqualifiedMedicarebeneficiarymusthave:• Twoormorechroniccondi<ons
Ø Nodefini<velist• Musthaveachroniccondi<onexpectedtolastatleast12months,orun<lthe
deathofthepa<ent;placespa<entatsignificantriskofdeath,acuteexacerba<on/decompensa<onorfunc<onaldecline.
18//experiencemomentum
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BENEFICIARYAGREEMENT
• GenngMedicareBeneficiaryagreementincludes,butnotlimitedto:
Ø Informthepa<entoftheavailabilityofCCMservicesandobtainhisorherwrijenagreementtohavetheservicesprovided.
Ø Informthepa<entthatonlyoneprovidercanfurnishandbepaidforCCMinacalendarmonth.
Ø Documentinthepa<ent’smedicalrecordthatalloftheCCMserviceswereexplainedandofferedtothepa<ent,andnotethepa<ent’sdecisiontoacceptordeclinetheseservices.
Ø Clinicmustcollectasignedpa<entagreementbeforebillingCCMØ Informthepa<entoftherighttostopCCMservicesatany<me.Ø Informthatcostsharingapplies.
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CCMCODINGANDBILLINGREQUIREMENTS
ChronicCareManagement(CPT99490)AccordingtotheCMSChronicCareManagementFactSheet,CPT99490isdefinedas
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CCMCODINGANDBILLINGREQUIREMENTS
WhoCanFurnishCCM:• Non-physicianprac<<oners(NPP)suchasnurseprac<<oner,physician
assistants,clinicalnursespecialistsandcer<fiedmidwives,canfurnishandbillMedicareforCCM,butonlytotheextentpermijedundertheirscopeofprac<ce.
• OtherNPP,suchasclinicalpsychologistsandsocialworkers,arenoteligible
tobill.• CMSwillreimburseonlyoneprac<<onerforprovidingCCMservicesper
calendarmonthandcanonlybebilledwhenatleast20minutesofnon-face-to-facecarecoordina<onservicesareprovided.
21//experiencemomentum
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CCMCODINGANDBILLINGREQUIREMENTS
• Codes/servicesthatcannotbereportedduringthesamemonthasCCM:
Ø Transi<onalcaremanagement(CPTcodes99495–99496)
Ø Homehealthandhospicecaresupervision(HCPCScodesG0181–G0182)
Ø End-stagerenaldiseaseservice(CPTcodes90951–90970)
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CCMTECHNOLOGYREQUIREMENTS
• Cer<fiedEHRmustbeusedfortherecordingofdemographicinforma<on,health-relatedproblems,medica<ons,andmedica<onallergies;aclinicalsummaryrecord;andotherscopeofservicerequirementsthatreferenceahealthormedicalrecord
• Mustusetechnologycer<fiedtotheedi<on(s)ofcer<fica<oncriteriathatis,ataminimum,acceptablefortheEHRIncen<veProgramsasofDecember31stoftheyearprecedingeachCCMpaymentyear
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CCMTECHNOLOGYREQUIREMENTS
Structuredrecordingofdemographics,problems,medica<ons,medica<onallergies,andcrea<onofstructuredclinicalsummaryrecordsusingCCMcer<fiedtechnology.
DocumentprovisionofthecareplanasrequiredtothebeneficiaryintheEHRusingCCMcer<fiedtechnology.
FormatclinicalsummariesaccordingtoCCMcer<fiedtechnology.Notrequiredtouseaspecifictoolorservicetoexchange/transmitclinicalsummaries,aslongastheyaretransmijedelectronically(otherthanbyfax).
Communica<ontoandfromhomeandcommunitybasedprovidersregardingthepa<ent'spsychosocialneedsandfunc<onaldeficitsmustbedocumentedinthepa<ent'smedicalrecordusingCCMcer<fiedtechnology
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1.QUALIFIEDPROFESSIONALS
WhichpracCConersareeligibletobillMedicareforCCM?
Ø Physicians
Ø Cer<fiedNurseMidwives
Ø ClinicalNurseSpecialists
Ø NursePrac<<oners
Ø PhysicianAssistants
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AqualifiedMedicarebeneficiarymusthave:• Twoormorechroniccondi<ons
Ø Nodefini<velist• Achroniccondi<onexpectedtolastatleast12months,or
un<lthedeathofthepa<ent;placespa<entatsignificantriskofdeath,acuteexacerba<on/decompensa<onorfunc<onaldecline.
26//experiencemomentum
2.QUALIFIEDMEDICAREBENEFICIARIES
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27//experiencemomentum
3.MEDICAREBENEFICIARYCONSENT
• AprovidercannotbillforCCMservicesunlesshe/shesecuresawrijenconsentfromthebeneficiary.
• Beneficiarymustacknowledgeproviderhasexplained(listnot
allinclusive):
Ø CCMprogram
Ø MannerinwhichCCMserviceswillbeprovided
Ø Healthinforma<onwillbesharedwithotherprac<<oners
Ø Onlyoneprac<<onercanprovidetheseservicesduringacalendarmonth
Ø BeneficiaryhastherighttostopCCMservicesatany<me
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4.NON-FACE-TO-FACECAREMANAGEMENTSERVICES
• Typeofservices(nonexclusive)
Ø Performingmedica<onreconcilia<on,oversightofbeneficiaryself-managementofmedica<ons
Ø Ensuringreceiptofallrecommendedpreven<veservices
Ø Monitorbeneficiary’scondi<on(mental,physicalandsocial)
• Documenta<onmustinclude:
Ø Dateand<me
Ø Personfurnishingservices
Ø Descrip<onofservices
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5.COMPREHENSIVECAREPLAN
Ø Createapa<ent-centeredcareplanbasedonphysical,mentalcogni<ve,psychosocial,func<onalandenvironmental(re)assessmentandaninventoryofresources(acomprehensiveplanofcareforallhealthissues).
Ø Providethepa<entwithawrijenorelectroniccopyofthecareplananddocumentitsprovisioninthemedicalrecord
Ø Ensurethecareplanisavailableelectronicallyatall<mestoanyonewithintheprac<ceprovidingCCMservice
Ø Sharethecareplanelectronicallyoutsidetheprac<ceasappropriate
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5.COMPREHENSIVECAREPLAN,CONT.
Ø Typicallyincludes(notlimitedto):Ø Problemlist
Ø Expectedoutcomeandprognosis
Ø Measurabletreatmentgoals
Ø Symptommanagement
Ø Plannedinterven<onsandiden<fica<onoftheindividualsresponsibleforeachinterven<on
Ø Medica<onmanagement
Ø Community/socialservicesordered
Ø Scheduleforperiodicreviewandrevisionofplan(whenapplicable)
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6.CCMCERTIFIEDTECHNOLOGY
Ø Requirestheuseofcer<fiedEHRtechnologytosa<sfymanyoftheCCMscopeofserviceelements
Ø Useofaversionofcer<fiedEHRthatisacceptableundertheEHRincen<veprogramsasofDecember31stofthecalendaryearprecedingeachMedicarePFSpaymentyearØ Forexample,technologyusedtofurnishCCMservices
beginningonJanuary1,2016,wouldberequiredtomeet,ataminimum,therequirementsincludedinthe2014Edi<oncer<fica<oncriteria.
Ø hjp://www.cms.gov/Regula<ons-and-Guidance/Legisla<on/EHRIncen<vePrograms
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CCMTECHNOLOGYREQUIREMENTS
EHRTechnologyRequirements:
• Mustu<lize“CMScer<fiedtechnology”forspecifiedpurposesinprovidingCCMservices
• Electronicallyrecordpa<entdata (i.e.,pa)entdemographicinforma)on;problemlist,medica)onsandmedica)onallergies,etc.)
• Allowforthecrea<onofastructuredclinicalsummary
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CCMTECHNOLOGYREQUIREMENTS
EHRTechnologyRequirements(cont’d)• Providermustbeabletotransmitthesummaryrecordforpurposesofcare
coordina<on.• HousethebeneficiaryconsentofCCMservices.• Housethebeneficiaryreceiptofcareplan.
• Documentcommunica<ontoandfromhome-basedandcommunity-basedproviders.
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CCMTECHNOLOGYREQUIREMENTS
ElectronicCarePlanRequirements• Planmustbeelectronicallyaccessible24/7toallcareteammembersinthehealth
centersthatareprovidingCCMservices.• Careplaninforma<onmustalsobeshared,asappropriate,withotherproviders
caringforthebeneficiary.• Abilitytoprovidepaperorelectroniccopytobeneficiary.
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CCMBILLINGANDCPTCODEREQUIREMENTS
ChronicCareManagement(CPT99490)AccordingtotheCMSChronicCareManagementFactSheet,CPT99490isdefinedas
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CCMBILLINGANDCPTCODEREQUIREMENTS
BillingCCMServices• CMSadoptedCPT99490forrepor<ngatleast20minutesofCCMpermonth.
• Non-physicianprac<<oners(NPP)suchasnurseprac<<oner,physicianassistants,clinicalnursespecialistsandcer<fiedmidwives,canfurnishandbillMedicareforCCM,butonlytotheextentpermijedundertheirscopeofprac<ce.
• OtherNPP,suchasclinicalpsychologistsandsocialworkers,arenoteligibletobill.• CMSwillreimburseonlyoneprac<<onerforprovidingCCMservicespercalendar
monthandcanonlybebilledwhenatleast20minutesofnon-face-to-facecarecoordina<onservicesareprovided.
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CCMBILLINGANDCPTCODEREQUIREMENTS
BillingCCMService(cont’d)§ Codes/servicesthatcannotbereportedduringthesamemonthasCCM:
Ø Transi<onalcaremanagement(CPTcodes99495–99496)
Ø Homehealthandhospicecaresupervision(HCPCScodesG0181–G0182)
Ø End-stagerenaldiseaseservice(CPTcodes90951–90970)Ø OverlapwithCMSdemonstra<onorotherini<a<vesthatpayforsimilar
services
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PROVIDERHEALTHCENTERREVENUEPOTENTIAL
PotenCalRevenuePerProvider• Basedonthena<onaldata,thetablebelowcalculatestherevenuepoten<alforasingle
providerbillingforCPT99490.IfaproviderperformsCCMservicesfortheircensusofqualifiedMedicarepa<ents,theiraddi<onalrevenuepoten<alissubstan<al.
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CONCLUSION
ThenewrulefromCMSallowingreimbursementforCCMservicesisahugechangethatwillallowphysiciansto:• Improvepa<entcareforMedicare
beneficiariesdealingwithchronicdiseases
• Nowgetpaidforworktheyarealreadydoingtocareforchronicallyillpa<ents
• Poten<allyincreaserevenuefortheirhealthcenterproviders.
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Office: 417.865.8701 Fax: 417.865.0682 www.bkd.com
Jacqueline R. Todd-Washington, BSM Managing Consultant [email protected]
Rebekah S. Wallace Pardeck, CMPE, CPC, MCS-P Director [email protected]
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DISCLAIMER
Theinforma<oncontainedinthispresenta<onisnotintendedtocoverallsitua<onsorallrulesandpolicies.Reimbursementlaws,regula<onsandpoliciesaresubjecttochange.
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