managing the cv care reemergence...apr 28, 2020 · this presentation is for general information...

© 2020 MedAxiom DO NOT DISTRIBUTE WITHOUT PERMISSION

MANAGING THE CV CARE REEMERGENCEBeginning to Prepare for Post-COVID Patient Needs – Part 1

April 28, 2020

PRESENTERS:• Ginger Biesbrock, PA-C, MPH, MPAS, AACC• Cathie Biga, MSN, RN, FACC• Nicole Knight, LPN, CPC, CCS-P• Terri McDonald, RN, MBA, CPHQ,

MODERATORS:• Jerry Blackwell, MD, MBA, FACC• Lori Walsh, MHSA

© 2020 MedAxiom DO NOT DISTRIBUTE WITHOUT PERMISSION 2

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[ ]DISCLAIMERThis presentation is for general information purposes only and is not intended and does not constitute legal, reimbursement, coding, business or other advice. Furthermore, it is not intended to increase or maximize payment by any payer. Nothing in this presentation should be construed as a guarantee by

MedAxiom regarding levels of reimbursement, payment or charge, or that reimbursement or other payment will be received. Similarly, nothing in this presentation should be viewed as instructions for

selecting any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and

veracity of all coding and claims submitted to third party payers. Also note that the information presented herein represents only one of many potential scenarios, based on the assumptions,

variables and data presented. In addition, the customer should note that laws, regulations, coverage and coding policies are complex and updated frequently. Therefore, the customer should check with their local carriers or intermediaries often and should consult with legal counsel or a financial, coding or reimbursement specialist for any coding, reimbursement or billing questions or related issues. This

information is for reference purposes only. It is not provided or authorized for marketing use.

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Cathleen Biga, MSN, FACCPRESIDENT/CEO, CARDIOVASCULAR MANAGEMENT OF IL [email protected]

EMERGENCE: LIVING WITH COVID


Like the Phoenix …we need to emerge

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TO A DIFFERENT WORLD

Short term cash flow strategy

A strategic, detailed, and phased emergence plan

Keep all your providers close –interventionalists perhaps a tad closer

Define and convene a governance committee

‒ NI‒ Cath Lab‒ EP‒ Clinic

Check your hospital’s plan

‒ System plan

Check your state’s Department of Public Health

Stay on top of CDC guidelines


COVID-19 Awarenessü Know your zip codeü Incidenceü Prevalenceü Clustersü CDC guidelines

Preparedness ü PPEü Testingü Supply chainü HR

Patient Safetyü Communicationü Screeningü Testingü Visitorsü Social Distancing

START YOUR PLANNING NOW

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Clinic• New pts• Symptomatic pts• Pts w/o video• Social distance• Masks• Logistics

Imaging • Testing – pts.• PPE – staff• Logistics• Longer hours

Procedures• Daily dashboard• Beds & ventilators • PPE, testing (HCW &

pt.)• Week behind clinic

Coming to grips with reality

OUR EMERGENCE

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Determine YOUR tier process for procedures

Implement new policies and procedures

Re-engage staff and listen to them

Develop and implement internal and external communication

Confirm you can manage “elective” procedures

SUMMARY


The Gottleib report (which was written by small team of public health, health security, epidemiological, and medical professionals) is one of the best reports we’ve seen that provides a map forward for re-opening the US: National Coronavirus Response - Gottlieb

This Harvard report (which cross-references some of Gottleib’s recommendations): Roadmap to Pandemic Resilience - Harvard's Center for Ethics

This NGA report has an excellent reference table in the Appendix (pages 29-33) that shows a side by side comparison of all the major reports/guidance published to date, and how they compare on each element: Roadmap to Recovery – National Governor’s Association

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REFERENCES

https://nam03.safelinks.protection.outlook.com/%3Furl=https%253A%252F%252Fwww.aei.org%252Fwp-content%252Fuploads%252F2020%252F03%252FNational-Coronavirus-Response-a-Road-Map-to-Recovering-2.pdf%253Futm_source%253Dnewsletter%2526utm_medium%253Demail%2526utm_campaign%253Dnewsletter_axiosvitals%2526stream%253Dtop&data=02%257C01%257CNoel.Araneta%2540amitahealth.org%257C27b21c291168486ebe5f08d7eaa936dd%257Cf81dc21ac1e5436c8b05d5f08b5a92bd%257C0%257C0%257C637235885093526681&sdata=V5NAYwwZbFnddqa%252B3JEwWubCfE5VGL6FhRxCFU%252BVqiw%253D&reserved=0

https://nam03.safelinks.protection.outlook.com/%3Furl=https%253A%252F%252Fethics.harvard.edu%252Ffiles%252Fcenter-for-ethics%252Ffiles%252Froadmaptopandemicresilience_updated_4.20.20.pdf&data=02%257C01%257CNoel.Araneta%2540amitahealth.org%257C27b21c291168486ebe5f08d7eaa936dd%257Cf81dc21ac1e5436c8b05d5f08b5a92bd%257C0%257C0%257C637235885093526681&sdata=bXFju5hbcGu%252BaBf8IL7aFRuyAtTyIbfU2A0WrXMEue4%253D&reserved=0

https://nam03.safelinks.protection.outlook.com/%3Furl=https%253A%252F%252Fwww.nga.org%252Fcenter%252Fpublications%252Fhealth%252Froadmap-to-recovery%252F&data=02%257C01%257CNoel.Araneta%2540amitahealth.org%257C27b21c291168486ebe5f08d7eaa936dd%257Cf81dc21ac1e5436c8b05d5f08b5a92bd%257C0%257C0%257C637235885093536674&sdata=opNqKDNZOJVDoqGe2nH25L9TiFpC1A4pfX4gSg8UTDo%253D&reserved=0


Whitehouse: https://www.whitehouse.gov/openingamerica/#criteriaCMS: https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf

The Guidelines for Opening Up

America Again can be found here:

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EMERGENCE…

https://www.whitehouse.gov/openingamerica/

https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf


Ginger Biesbrock, PA-C, MPH, MPAS, AACCSENIOR VICE PRESIDENT, CONSULTING

COVID #4 UPDATE


COVID-19 Surveillance

COVID-19 Safety –Employees and Patients

Reemergence Preparedness –Defining the New Normal

Develop a Task Force – with Representation from All Areas

Considerations

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REEMERGENCE


Physician Champion(s)AdministratorClerical - scheduling, registrationClinical - MA, RN, APPRevenue CycleImaging, Ancillary, Procedural Services

Key Stakeholders

REEMERGENCE TASK FORCE

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Ambulatory Clinic and Imaging

Procedural Care Ancillary Services and Revenue Cycle

Where to Start

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REEMERGENCE


COVID-19 Positive • Worker

‒ Definitions for safety to return

‒ Plans for quarantine of those possibly exposed

• Patient

COVID-19 Person Under Investigation

MUST-HAVE POLICIES

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COVID-19 SCREENING POLICY

Staff• Screening daily

Patient • Screening day prior• Screening day of• Possible testing for those

that undergo procedure or possible imaging


All staff should wear a face mask

Patients should wear face masks from home – or be provided one in the office

Assure hand washing and sanitizer stations to your infectious disease code

Room cleaning and wipe down

Definitions for terminal clean requirements

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COVID-19 PPE AND CLEANING POLICY


Review of Facility:

• Are you part of a hospital campus, building? • Setting up ‘clean’ entrances and exits• Option for providing care in the car?

• Coumadin clinics• Imaging areas – are they shared with inpatients?• Procedural areas – are they shared with inpatients

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Non

-CO

VID

C

are

Zone

s:


• 6 feet apart• Waiting in car

with text or pager when ready

• Discourage additional visitors (limit to 1 caretaker)

• Pre-register with virtual if possible

• 6 feet with separation of registrar and patient – review your facility

• Minimize ‘touches’

• Paper vs portal

• Pre-visit phone call

• Weights, blood pressure and 02

Waiting Room Registration Patient Rooming

• Room check-out for simple

• Virtual check-out for complex

• Develop separate processes to minimize touchpoints

Check-out

PATIENT FLOW CONSIDERATIONS

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Limit patient flow

Spread your clinics out throughout the week – extend hours

Evaluate clinic capacity – reduce to appropriate # of maintain social distancing

Develop a clinic triage plan

PATIENT SCHEDULING PEARLS

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Develop clinical care pathway based on patient type:

Acute NeedsUrgent Needs – high risk chronic disease managementStable Needs – chronic disease managementPrevention

Delivery options:Face-to-face office visitsTelehealth visitsRemote patient monitoring, chronic care management

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CLINIC TRIAGE PLAN


Ambulatory Management FrameworkAcute & New Patient Chronic Disease Mgmt. Prevention

In Office In OfficeIn Office

Telehealth Telehealth

Remote Patient Monitoring

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TELEHEALTH VISIT FLOW

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FACE-TO-FACE VISIT FLOW

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STRESS TESTINGCONSIDERATIONS

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Ginger Biesbrock, PA-C, MPH, MPAS, AACCSENIOR VICE PRESIDENT, CONSULTING


• Level of risk of patient transmitting COVID-19 to imaging team

• *Urgency of performing the test

• COVID screening question

• Instructions/what to expect for the day of the test

PRE-TEST CONSIDERATIONS

1 2Evaluate for: Call patient day prior:


Screen patient for COVID risk +/- temperature

All patients should wear facemasks

Maintain 6 feet as much as possible

Patient should come alone if possible

All patient-facing staff should wear a facemask at all times

DAY OF TEST CONSIDERATIONS


If COVID suspected, one tech to don PPE and other to run the scanner

Terminal clean if patient COVID+ or concerns for COVID+

ALL equipment should be cleaned between each test in compliance with local infection control policies

Minimize # of staff required to provide face to face patient interaction and minimize amount of time with patient by assuring all needs are met with each interaction

DURING TEST CONSIDERATIONS - NUCLEAR

Guidance and Best Practices for Nuclear Cardiology Laboratories During the Coronavirus Disease 2019 (COVID-19) Pandemic: An Information Statement from ASNC and SNMMI 30

https://zenodo.org/record/3738020


Plan ahead for echo to allow for focused sequences of images that are needed for decision making

Consider increased use of ultrasound enhancing agent to improve image acquisition

Minimize scan times by excluding students and novice practitioners

DURING TEST CONSIDERATIONS - ECHO

https://www.asecho.org/ase-statement-covid-19/31

https://www.asecho.org/ase-statement-covid-19/


Select protocol with shortest duration of scan timeSingle day or stress only Consider PET if available – faster throughputConsider minimize treadmill use – utilize pharmacologic as preferred for both echo and nuclearConsider pharmacologic agent with shortest infusion time, etc.

Goal is to minimize exposure

PROTOCOL CONSIDERATIONS

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RESUMING INVASIVE LAB OPERATIONSWhat Does That Look Like?

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Terri McDonald, RN, MBA, CPHQVICE PRESIDENT, CONSULTING


Protect the health and safety of patients,

healthcare workers, and the community through

mitigating the risk of viral spread

*Creating Non-COVID Care (NCC) Zones*

Resume interventional procedures essential to

cardiovascular health for our patients

PLAN WITH OVERARCHING PRINCIPLES

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Multidisciplinary, authorized to make real-time decisions: clinical, operational, financialAwareness of community statusDefine and implement policiesDynamic management and application of emerging information and knowledgeOversight of outcomes, with a plan for potential return to containment

Steering/ Governance

Team

WHERE TO START?

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Hospital/System Leadership and Infection Prevention Team

Chain of command for your community: state, county, municipal

ACC's COVID-19 Hub

MedAxiom COVID-19 Resources for CV Organizations

Key

Res

ourc

esLOCAL, REGIONAL AND NATIONAL TRENDS

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https://www.acc.org/latest-in-cardiology/features/accs-coronavirus-disease-2019-covid-19-hub

https://www.medaxiom.com/covid-19-resources/


ü Initial COVID-19 screening questionnaire

ü Pre-procedure assessments (nursing, anesthesia, H&P)

ü Patient educationü Registration/questionnaires

ü Access to clinical personnel for issues

ü 24-hour follow-up call post-procedure

ü Consider post procedure screening for COVID/ILI at seven and 14 days

ü Post procedure provider visit (routine guidelines)

Pre-procedure

IT infrastructure should support minimizing in-person interactions

LEVERAGE VIRTUAL/TELEHEALTH RESOURCES

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Post-procedure


CONSIDERATIONS FOR TIMING (PHASE ONE)

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Access to/level of testing

Sustained reduction in average number of cases for 14 days in your geography

Authorized by appropriate authorities

Hospital not at crisis level

(Example)

Zip

Cod

e M

atte

rs


• Return repurposed areas/equipment to use

• Maintenance and safety checks

• Engineer screening at all entry points and social distancing where possible

• Everyone masked, at all times

• Standard full -barrier precautions in procedures*

• Adequate supply without reuse

• Policies for use and conservation of supply

• Uninterrupted supply chain

• Inventory adequate to support sustained operation

• Policies for Industry Rep

Facility PPE Supply Chain

• Adequate number of trained and educated staff available

• Staffing plan supports gradual resumption of case volumes

• EVS support

Staffing

And turn the faucet back on slowly in Phase One

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ACTIONS/RESOURCES TO CREATE NCC ZONES

*Healthcare Infection Prevention and Control FAQs for COVID-19


Sensitive to the institution’s resources, priorities, and patient needs – Phase One will drive SDD as a priority

Transparency in process

Defined, evidence-based criteria, begins with an assessment of the backlog

Dynamic – will be modified as more COVID-related outcome data become available

Collaborative, multidisciplinary collaboration – Steering Committee authority

*Cre

ate

Fram

ewor

kCASE PRIORITIZATION

40*Source: Local Resumption of Elective Surgery Guidance (ACOS April 2020)


In hospital-based labs reserve one lab for known COVID-19 and PUI (urgent/emergent) if possible; this is core work/staffing *lab turn-around time considerations*

Start week 1 at 25% elective capacity with block scheduling (adjust starting point as resources allow)

Evaluate and adjust weekly (Steering Committee oversight)

RESUME/RAMP-UP PLAN: PHASE ONE

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REVENUE CYCLECONSIDERATIONS

Nicole Knight, LPN, CPC, CCS-PVICE PRESIDENT REVENUE CYLE SOLUTIONS AND CONSULTING


Maintaining Virtual Clinics – Coumadin, Device, Telehealth Visits

How to Make Remote Patient Monitoring (RPM) Happen?

Exploring Chronic and Principle Care Management (CCM, PCM) Opportunities

Pre and Post Visit Prep and Planning

CONSIDERATIONS

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• Registration, ID, Insurance Card • Insurance Verification• Referral and/or Authorization Requirements• Patient Responsibility• Considerations of Electronic/Digital Signature forms

• Ensure all registration and insurance eligibility is done• Collections prior to visit – growing self insured.

• Appointment or recall is crucial• Schedule and/or coordinate labs, testing, etc.• Orders reconciliation process

Pre-Visit

At the Visit

Post Visit

In-Person or Virtual SAME

Considerations

VISIT PREPARATION AND PLANNING


Remote Device Clinics – pacemaker, ICD, Optivol, etc.

Accountability and ownership of virtual services that may not have existed with movement to safe in person visits

Coumadin Clinic – Capturing management codes, home INR, % require in-person, continuing curb side.

#1 = What % will require in-person? Solid process to capture charges/time- frames and any potential overlapping services.

MAINTAINING AND CONVERTING SERVICES

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Expiration date? Moving forward w/ telehealth

Patients loss to follow – no shows, cx’s, recalls, etc.

Out of hospital patients – TCM

Challenges with technology

Reimbursement and guidance – Medicare vs. commercials

Denials, re-work of claims, etc.

TELEHEALTH PLANNING

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WHAT WE KNOW NOW

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Telehealth for CMS remains AUDIO and VIDEO

Some commercial payers are paying for regular EM’s for just telephone – variable by state.

Challenges with cost sharing, copays, legal and compliance –key is to be consistent across your program.

Hospital visits, consults, etc. remain a gray zone – programs doing what makes sense..

Claims processing versus holding

Denial management – tracking and re-work


• Provider Prescription and/or Order Required

• Annual Consent Required -may be verbal or written

• Education on coinsurance, copay, etc.

DURING COVID PHE• New and Est pts

• Chronic or Acute Conditions

• Device = FDA’s definition of medical device.

• Device capable of generating and transmitting recordings of the pt’sphysiologic data..

• Consideration of the data collected and integration.

• If supplying device - must be supplied for at least 16 days to bill. Understand requirements of lease or purchase of equipment

• May be performed by the MD, QHP, or by clinical staff depending on the CPT.

• Clinical staff may include RNs and MAs, depending on state law.

• General Supervision 2020

• No previous visit 7 days prior or in 24 hrs/soon as possible.

• Not allowed for RHC and FQHCs

• May be reported with TCM, CCM but no double counting time.

Pt. Eligibility Technical Regulatory

Areas of Guidance

REMOTE PATIENT MONITORING (RPM)

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DURING COVID PHE – FDA Expanded use of RPM devices


Coding and Billing

RPM REV CYCLE

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Click here to access MedAxiom’s Virtual Services Tool

https://www.medaxiom.com/resource-center/value-reimbursement-and-population-health/medaxiom-virtual-services-coding-tool/%3Fback=ResourceCenter&lpct=MjYuYS4yMDIwLTA0LTI4


CLINICAL DOCUMENTATION

Consent – verbal or written Capturing the dates and actual time spent providing the non-face to-face services for the 30-day period

Care team member providing services (with credentials if applicable)

A brief description of the services provided• Data Monitoring: reviewing incoming

data, discussing data with patients, flagging areas of concern, etc.

• Managing Interventions: making medical decisions based on data, reaching out in emergency situations, discussing medical changes with patients, etc.

CMS has not defined what constitutes a “live interactive communication,” we assume a face-to-face visit, an interactive video conference or a conversation by telephone or text message should be sufficient

Attestation of the provider i.e. signature (support general supervision, review, etc.)


Option for managing 1 or more chronic illnesses

Consideration for support from care team – general supervision

Improved care coordination, outcomes, engagements, etc.

Impact on revenue – non face to face services. Studies show $75,000 + per provider annual revenue.

Virtual enrollment – E&M and if applicable G0506 – CCM Initiating Visit via Telehealth

Comes with documentation and reimbursement requirements

CONSIDERING CCM OR PCM

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MedAxiom.com/COVID19

MEDAXIOM’S COVID-19 RESOURCES

https://www.medaxiom.com/covid-19-resources/


ACCESS THE TOOL

https://www.medaxiom.com/resource-center/value-reimbursement-and-population-health/medaxiom-virtual-services-coding-tool/%3Fback=ResourceCenter&lpct=MjYuYS4yMDIwLTA0LTA5


TAKE THE SURVEY

SURVEY ON STEMI AND STROKE VOLUMES

https://www.surveygizmo.com/s3/5559533/COVID-19-Acute-Cardiovascular-Events


Q&A56


• ACC/SCAI Consensus Document: Triage For Structural Heart Disease During COVID-19 Pandemic - American College of Cardiology

• ACC/SCAI/ACEP Consensus Statement on Management of AMI Patients During COVID-19 -American College of Cardiology

• Guidance for Cardiac Electrophysiology During the Coronavirus (COVID-19)

RESOURCES FOR CV CASE PRIORITIZATION

• CDC: Coronavirus (COVID-19)• CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or

Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings• Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19• Opening Up America Again | The White House• Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic• AORN Townhall: Roadmap for Resuming Elective Surgery - What it Means to You on the Front Line

ADDITIONAL RESOURCES

https://www.acc.org/latest-in-cardiology/articles/2020/04/06/12/49/acc-scai-consensus-document-guides-triage-for-structural-heart-disease-during-covid-19

https://www.acc.org/latest-in-cardiology/articles/2020/04/20/14/45/acc-scai-acep-release-consensus-statement-on-management-of-ami-patients-during-covid-19

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047063

https://www.cdc.gov/coronavirus/2019-ncov/index.html

https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html

https://www.whitehouse.gov/openingamerica/

https://www.aorn.org/guidelines/aorn-support/roadmap-for-resuming-elective-surgery-after-covid-19

https://youtu.be/SXZuJFX26SQ


• https://www.heart.org/-/media/files/about-us/policy-research/policy-positions/clinical-care/remote-patient-monitoring-guidance-2019.pdf?la=en&hash=A98793D5A043AB9940424B8FB91D2E8D5A5B6BEB

• https://www.ama-assn.org/amaone/ama-digital-health-implementation-playbook

• https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf

• https://innovation.cms.gov/files/reports/chronic-care-mngmt-finalevalrpt.pdf

• https://www.cdc.gov/coronavirus/2019-ncov/downloads/critical-workers-implementing-safety-practices.pdf

RESOURCES

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https://www.heart.org/-/media/files/about-us/policy-research/policy-positions/clinical-care/remote-patient-monitoring-guidance-2019.pdf%3Fla=en&hash=A98793D5A043AB9940424B8FB91D2E8D5A5B6BEB

https://www.ama-assn.org/amaone/ama-digital-health-implementation-playbook

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf

https://innovation.cms.gov/files/reports/chronic-care-mngmt-finalevalrpt.pdf

https://www.cdc.gov/coronavirus/2019-ncov/downloads/critical-workers-implementing-safety-practices.pdf


Cathleen Biga, MSN, FACCPRESIDENT/CEO CARDIOVASCULAR MGMT OF IL [email protected]

Nicole Knight, LPN, CPC, CCS-PVICE PRESIDENT REVENUE CYLE SOLUTIONS AND [email protected]

Terri McDonald, RN, MBA, CPHQVICE PRESIDENT, [email protected]

Ginger Biesbrock, PA-C, MPH, MPAS, AACCSENIOR VICE PRESIDENT, [email protected]

managing the cv care reemergence...apr 28, 2020 · this presentation is for general information...

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