CROSSING THE HURDLES: CMS PROPOSED CHANGES TO E/M CODING

Transcription

1 CROSSING THE HURDLES: CMS PROPOSED CHANGES TO E/M CODING KENTUCKY PRIMARY CARE ASSOCIATION OCTOBER 6, :00 TO 4:00 P.M. PRESENTED BY: MARLA DUMM, CPC, CCS-P MANAGING CONSULTANT BKD, LLP

2 OUR GOALS FOR TODAY Understand the Why of the CMS Proposal to Revise E/M Documentation Requirements Identify Current and Proposed E/M Documentation Reductions Understand Proposed Collapsed Coding Model, Add-On Codes, and Potential Reimbursement Impact Q&A 2

3 WHAT PROMPTED THE CMS CY2019 PROPOSED CHANGES? 40% of clinical professional receive reimbursement for E/M services under the Medicare fee schedule ¾ of a million clinical providers utilize E/M CPT codes Estimated 51 hours per year spent in documentation tasks There have been no updates to the documentation requirements since 1997 Clear and concise documentation is critical but providers spend more time doing paperwork and less time on fostering the doctor/patient relationship A loss of that personal touch Documentation focus has moved to supporting billing requirements versus on capturing accurate information about pertinent facts, findings and observations 3

4 CURRENT E/M LEVEL OF SERVICE CRITERIA Model of five levels based on the patient type and site of service New office patient Established office patient is reserved for eligible ancillary staff services Providers may assign the new or established levels based on complexity of work performed, the patient condition(s) evaluated, and the treatment plan Levels of service are determined on the level of history, examination and medical decision making supported. Levels of service may be determined by the time if counseling and/or coordination of care is supported 4

5 WHAT PROMPTED THE CMS CY2019 PROPOSED CHANGES? President Trump signed an Executive Order directing federal agencies to cut the red tape CMS Administrator Seema Verma championed the Patients Over Paper Initiative to reduce administrative burden and unnecessary duplicative documentation that is not useful toward patient care Overall goal: Streamline governmental regulations Reduce unnecessary administrative burden on providers Increase process efficiencies Reduce healthcare costs Improve overall beneficiary experience 5

6 WHAT HAS ALREADY BEEN CHANGED? Implemented a Targeted Probe and Educate program Better targets CMS medical review processes Focused efforts on providers who may have unusual billing patterns or practices (identified through data analysis) Limits the number of records requested Emphasizes education and assistance in correcting identified claims errors Clarified signature/authentication requirements Only the person responsible for the patient s care needs to sign the medical record entry for payment purposes If the physician s authenticated documentation corroborates the nurse s unsigned note, and the physician was the responsible party per Medicare s payment policy, medical reviewers would consider signature requirements to have been met. Source: Medicare Program Integrity Transmittal 751 6

7 WHAT HAS ALREADY BEEN CHANGED? Revised documentation criteria for teaching physician personal performance criteria, authentication and utilization of medical student documentation Effective on or after March 5,

8 MEDICAL STUDENTS - RULES EFFECTIVE ON OR AFTER MARCH 5,

9 MEDICAL STUDENTS TAKE-AWAYS Effective March 5, 2018 Students documentation of the cc, HPI, ROS and PFSH may be used toward the level without re-work/redocumentation by the teaching provider if verified The teaching physician must still personally perform, or re-perform, the physical exam and decision making activities, but the elements performed and documented by the student may be verified and, if so, would not need to be re-documented The combined information will be eligible toward the level of service assignment Both the student and the teaching physician must authenticate their portions of the documentation Applies to any student type 9

10 FINAL RULE CY2019 CHANGES 10

11 PROPOSED AND FINAL E/M SERVICE CHANGES CY2019 Eliminating the requirement to document the medical necessity of furnishing services in the home setting versus in the office/clinic. This rule was finalized effective 1/1/19 Eliminating the CMS manual provision that does not allow payment for two E/M office visits billed by a physician (or physician or the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus-outpatient hospital, or on-campus, outpatient hospital setting which could not be provided during the same encounter. Source: Medicare Claims Processing Manual, Chapter 12, Section B This rule was tabled and make take effect in the future 11

12 PROPOSED E/M DOCUMENTATION CHANGES HISTORY Removing redundant documentation: Would remove the requirement for the rendering (i.e., billing) physician or non-physician practitioner to repeat pertinent ROS or PFSH documented by the patient or by ancillary staff If there is evidence that the rendering provider has reviewed or updated the information, nothing would need to be re-recorded Would remove the requirement for the rendering physician or nonphysician practitioner to re-document the chief complaint and/or history of present illness previously obtained by ancillary staff Other than pertinent information gathered by the rendering provider during their conversation with the patient Both changes were finalized for E/M new and established office visit documentation, effective 1/1/19 12

13 PROPOSED E/M DOCUMENTATION CHANGES TEACHING PHYSICIANS Revision of the requirement to document the presence of the teaching physician at the time of service (by the resident) The presence of the teaching physician could be supported by notes in the medical record by the teaching physician, resident or nursing staff CMS finalized the amendment of the requirement for teaching physicians to document the extent of their participation in the review and direction of services furnished by a resident. A new paragraph was added, stating the medical record must document the extent of the teaching physician s participation in the review and direction of services furnished to each beneficiary, and that the extent of the teaching physician s participation may be demonstrated by notes made by a physician, resident or nurse Physicians will still be required to review the resident documentation for accuracy and agreement, and notate that agreement or any changes. 13

14 PROPOSED CHANGES LEVEL OF SERVICE ASSIGNMENT Provider would have a choice in how they assigned their level of service They could use the current model (utilizing the level of history, exam and MDM) or one of the following: Use medical decision making (MDM) as the sole determining factor Use the amount of time (start/stop) spent face-to-face with the patient and rendering provider Regardless if visit was for work other than counseling or coordination of care Would encourage the removal of the boilerplate or template documentation content This proposal was NOT finalized, but delayed to CY

15 PROPOSED E/M SERVICE REIMBURSEMENT CHANGES CY2019 CMS would implement a collapsed E/M reimbursement model A single, blended payment Applicable to E/M codes and Additional add-on codes would be established to reflect add-on payments for distinct work Due to the single payment system, providers would only need to document at a minimum the information to support a level 2 visit (except when using time for documentation) Source: CMS, Calendar Year (CY) 2019 Medicare Physician Fee Schedule (PFS) Proposed Rule, Documentation Requirements and Payment for Evaluation and Management Visits & Advancing Virtual Care 15

16 PROPOSED ESTABLISHED VISIT PAYMENT MODEL CY

17 PROPOSED NEW VISIT PAYMENT MODEL CY

18 PROPOSED NEW VISIT PAYMENT MODEL - RVUS 18

19 FINAL RULE DELAYED PAYMENT CHANGES TO

20 USE OF TIME TO DETERMINE LEVEL - PENDING Still taking comments on how a time based level of service would correlate with the new payment models Will determine what total time will be required under the new single, blended payment rate for levels of service 2-5 Documentation of the typical amount of start/stop time would still be required Not finalized for Pending review and delayed until CY

21 PROPOSED ADD-ON CODES PRIMARY CARE CMS has proposed additional add-on codes to reflect distinct resources involved during a primary care visit Visits involve non-face-to-face work and other primary care services that are not fully captured in the levels of service GPC1X Visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services (assign in addition to an established evaluation and management visit) Work RVU 0.07 Physician Time 1.75 minutes Practice Expense 0.07 Malpractice 0.01 Payment Estimate $5 21

22 PROPOSED ADD-ON CODES SPECIALTY CARE CMS has proposed additional add-on codes to reflect distinct resources involved during a specialist visit Visits involve non-face-to-face work and other specialty care services that are not fully captured in the levels of service GCG0X Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology, or interventional pain management-centered care (assign in addition to an established evaluation and management visit) Work RVU 0.07 Physician Time 1.75 minutes Practice Expense 0.07 Malpractice 0.01 Payment Estimate $5 22

23 PROPOSED ADD-ON CODES PROLONGED SERVICES CMS has proposed an add-on code to reflect distinct resources involved with a 30 minute prolonged E/M visit NOTE: CMS has indicated that psychiatrists would not use this new G code as CPT code is available for them to assign for services provided outside the description of the psychotherapy service GPR01 Work RVU 1.17 Payment Estimate $67 23

24 FINAL RULE DECISION Add-On codes for additional primary care or specialty care E/M work were NOT finalized for 2019 The codes will be delayed, with additional review, until The collapsed E/M office visit reimbursement model has been delayed until CY

25 COMPARISON OF CURRENT AND BLENDED FFS PAYMENT RATES TIP: RHCs and FQHCs could use a similar tool to forecast potential impact IF CMS or State Medicaid plans implement similar payment models We just don t know! 25

26 ADDITIONAL PROPOSED CHANGES MODIFIER 25 CMS has proposed to reduce payment by 50% for the least expensive procedure that a provider renders on the same day as an E/M service Currently, modifier -25 is assigned to reflect a distinctly, separate procedure or service performed in addition to an E/M service The proposed reduction would be applied to the procedure or other diagnostic/therapeutic service CMS is offsetting the cost of the new add-on code payments for the E/M codes with this reduction This change was NOT finalized for CY

27 ADVANCING VIRTUAL CARE CMS is proposing: Payment for virtual check-ins Brief, non-face-to-face assessments via communication technology Payment for RHCs or FQHCs to perform distant site professional services and other communication based services when there is not associated billable (i.e., FTF) service Expanding telehealth services to include prolonged preventive services Final Rule changes effective 1/1/19: RHCs and FQHCs will be paid for HCPCS G0071 (Virtual Communication Services) Listed on a UB-04 claim alone or with other payable services Requires at least 5 documented minutes of communication technology based or remote evaluation services furnished by a RHC or FQHC core provider who has had a billable visit within the previous year, and the medical discussion or remote evaluation is for a condition NOT RELATED to a RHC or FQHC service provided within the previous 7 days, and does not lead to a billable visit within the next 24 hours or soonest available appointment. 27

28 INDUSTRY COMMENTS TO CMS

29 THIS IS JUST PROPOSED AT THIS POINT Final rule was released November 1st Several of the documentation changes that will remove redundancy were finalized There is significant industry concern about the new payment models Due to anticipated reduced reimbursement Inaccurate assessment of resources under the add-on codes, unfairly skewed toward the specialty providers There is significant industry concern about the new options for assignment of level of service How will auditing be conducted? How will compliance be established? Will non-medicare payers implement similar guidelines? Will the AMA restructure the current E/M descriptions and criteria? Will these guidelines impact other site of service codes? 29

30 PUTTING THE PIECES TOGETHER Keep tuned! Forecast any potential revenue impact that might impact RHC and/or FQHC in CY2021 Have a plan of action in place in the event the CMS documentation changes are finalized Communicate with vendors or internal IT staff for any EMR documentation tool updates Develop internal policy developed that meets the guidelines and the needs of the professional staff Update current compliance plans and audit policies to meet the new criteria Educate, educate, educate!!! 30

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32 REFERENCES American Medical Association, Current Procedural Terminology (CPT) 2018, Professional Edition Centers for Medicare and Medicaid Services, 1995 and 1997 Documentation Guidelines for Evaluation and Management Services 2019 Medicare Physician Fee Schedule: Final Rule CMS (Webinar), Calendar Year (CY) 2019 Medicare Physician Fee Schedule (PFS) Proposed Rule- Documentation Requirements and Payment for E/M Visits & Advancing Virtual Care

33 REFERENCES American Academy of Family Physicians (AAFP), FPM Journal, Evaluation and Management Coding and Documentation Burden Could Lighten in 2019 Under CMS Proposed Rule, Richelle Marting, JD, July 13,

34 COPYRIGHT "CPT codes copyright 2018 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use. 34

35 DISCLOSURE Information contained in this presentation is informational only & is not intended to instruct physicians on how to use, or bill for health care procedures. Providers should consult with their respective insurers, including Medicare fiscal intermediaries & carriers, for specific information on proper coding & billing for health care procedures. Additional information may be available from physician specialty societies & hospital associations. Information contained in this presentation is not intended to cover all situations or all payers' rules & policies. Reimbursement laws, regulations, rules & policies are subject to change.

36 Marla Dumm, CPC, CCS-P, Managing Consultant // x 23083