Tune-Up Your Check Up, Mississippi! Jonathan Shook, MD, FAAP April 21, 2017

Transcription

1 Tune-Up Your Check Up, Mississippi! Jonathan Shook, MD, FAAP April 21, 2017

2 Tune-Up Your Check Up, Mississippi! Topics in Well Child Care, Coding, Documentation, and Payment. Jonathan Shook, MD, FAAP April 21, 2017

3 Disclosures In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. With the exception of membership on the UnitedHealthcare Community Plan of Mississippi Provider Advisory Committee I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

4 Opening Remarks Coding info changes over time Anti-trust laws prohibit mentioning any specific payment amounts for private insurers or MS CHIP Medicaid fee schedule is public info Thanks to my partners/managers and MS AAP colleagues Medicaid Medical Director Dr. Tami Brooks!

5 Objectives Discuss recommendations for preventive pediatric health care from AAP Bright Futures Coding/documentation requirements Discuss payment environment in MS for childhood preventive services Address FAQs about pediatric coding and reimbursement in MS

6 Medscape Physician Compensation Report 2017

7 Financial Benefits of Well Visits in MS MS Medicaid increased payments for primary care services in 2013 Payments for primary codes must = Medicare e.g. Well infant visit 99391= $92.26 is comparable to many private payors

8 Well visits have higher RVU value Most common problem visit: 99213= 2.06 RVU= $73.93 (100% Medicare) Well visit for 5-11 year old: 99393= 2.97 RVU= $ (100% Medicare)

9 Separately reimbursed services add up! Vaccine admin, hearing/visions screens, developmental/autism screens, depression screens, fluoride varnish, labs, etc. EPSDT: infant high risk screens, oral health assessments, adolescent counseling

10 Well Visits 29% of all visits for children % of all visits for infants. Most should involve immunizations. Comprise 25-50% of visits for most pediatric primary care practices

11 CPT Definition of Well Visit: Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions.

12 What is Bright Futures? National health promotion and prevention initiative, led by the AAP and supported by the Health Resources and Services Administration (HRSA) Bright Futures Guidelines provide theorybased and evidence-driven guidance for all preventive care screenings and well-child visits.

13 Components of a Bright Futures Visit

14 Bright Futures Relevance Under Section 2713 of the ACA, private health plans must provide coverage for a range of preventive services and may not impose costsharing on patients receiving these services. Apply to all private plans except for those with grandfathered status (existed prior to 2010 without making significant changes to their coverage since then).

15 Bright Futures in the ACA Required preventive services come from recommendations made by 4 expert medical and scientific bodies U.S. Preventive Services Task Force (USPSTF) Advisory Committee on Immunization Practices (ACIP) Health Resources and Services Administration s (HRSA s) Bright Futures Project HRSA and the Institute of Medicine (IOM) committee on women s clinical preventive services.

16 Affordable Care Act (ACA) ensures that children enrolled in all individual and group non-grandfathered health care plans receive the gold standard of preventive care all preventive care screenings and services recommended by the AAP/Bright Futures without cost-sharing.

17 ACA Loophole? What does without cost-sharing mean? No copayments, deductibles, or co-insurance For a recommended preventive service with its own CPT code, it means a separate payment, or bundling of services 1 payment for 2 or more separate services during the same patient visit that results in decreased payment to the provider. From CPT: Immunizations and ancillary studies involving lab, radiology, or other procedures, or screening tests (e.g., vision, developmental, and hearing screening) identified with a specific CPT code, are reported separately from the preventive medicine service code. From AAP: To ensure that all services children need are provided, it is critical that insurers pay for each separately reported service at a level that reflects the total RVUs of all separately reported services at each visit.

18 Bright Futures in MS MS Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Agreement updated 12/16: Must agree to adhere to the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule for physical, mental, psychosocial and/or behavioral health, vision, hearing, adolescent and developmental screenings when conducting EPSDT screenings. MS EPSDT Website Different payers have nuances in regard to coverage of Bright Futures components.

19 P e r i o d i c i t y S c h e d u l e Available at:

20 Bright Futures Implementation: Lessons Learned Change and improvement is a Journey! Need more appointment availability Opportunity to add providers Well child care is great use of a mid-level practitioner Patients need education on benefits of well visits Shots not only purpose of visits

21 Where do we start our Bright Futures Journey? Each clinic/organization needs a Bright Futures champion Manager/administrator needs to be highly involved and motivated Entire clinic (receptionists, nurses, techs, etc.) needs to be involved and educated

22 Where do we start our Bright Futures Journey? Periodicity <8 day old well visit? 30 month visit? Recall/reminders for school ages Templates and Questionnaires DOM and AAP websites with good examples Involve support staff for help

23 Notable MS EPSDT changes via Bright Futures Only universal screening H/H is at 12 months Vision screens start at 3 years; every other year in school ages, no plus lens test Hearing screens start at 4, every other year in school ages No universal RPR for 15 years and up

24 Notable MS EPSDT changes via Bright Futures <8 day old well visit and 30 month visit Standardized developmental screen Autism screen Adolescent Depression screen Adolescent Tobacco and Drug screen Adolescent Hearing Screen Universal Dyslipidemia screen Universal HIV screen Maternal Depression Screen (coming soon)

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26 First Week Visit (3 to 5 Days)

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28 2 ½ Year Visit

29 Standardized Developmental Screening Bright Futures calls for developmental screening at 9, 18, and 30 (or 24) months. Screening tool can also be used (and reimbursed for) at a problem visit for a related concern. CPT Examples: Ages and Stages Questionnaire (ASQ) Parents Evaluation of Developmental Status (PEDS) Survey of Well-Being of Young Children (SWYC) NOT direct observation or general checklist of milestones for age (surveillance)

30 Developmental Screening Performed or scored by nurse or other trained personnel. Parent/guardian report of behavior. Document interpretation in E/M visit note. Example: Ages and Stages results were normal (or insert abnormal). Reviewed and discussed. Modifier -25 may be attached to associated E/M visit.

31 Standardized Autism Screening Bright Futures calls for autism specific screening at 18 and 24 months. Modified Checklist for Autism in Toddlers (MCHAT) has recently been revised to MCHAT-R MCHAT can also be used (and reimbursed for) at a problem visit for a related concern. CPT 96110

32 Social/Emotional & Behavior Screens Recommended at every well visit CPT Brief emotional/behavioral assessment with scoring and documentation, per standardized instrument Examples: Ages and Stages Questionnaire- Social Emotional (ASQ-SE) Pediatric Symptom Checklist Behavior Assessment Scale for Children 2nd Edition (BASC-2) Many others

33 Bright Futures Oral Health Fluoride Varnish Application After tooth eruption, fluoride varnish may be applied to all children every 3 6 months in the primary care or dental office. USPSTF gave it a Level B recommendation. ACA says it must be covered Private payers: CPT Reimbursement will vary in amount and frequency CPT requires a physician or other qualified health care professional to perform. No RN or staff

34 Bright Futures Oral Health All MSCAN and Medicaid patients: Oral health assessment and fluoride varnish application: Can be billed twice per fiscal year, at least 5 months apart, for patients between 6 months and 3 years old. D0145: oral evaluation & counseling = $37.87 DOM D1206: fluoride varnish application = $22.42 Fluoride cost is less than $2 per dose.

35 Tobacco, Alcohol, or Drug Use Assessment Yearly beginning at 11 years old Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument Example: CRAFFT- series of 6 questions to screen adolescents for high risk alcohol and other drug use disorders simultaneously. If answer to first 3 are no, then can stop screen

36 Adolescent Depression Screening Yearly starting at 12 years old Patient Health Questionnaire (PHQ-2 or PHQ-9) CPT Brief emotional/behavioral assessment with scoring and documentation, per standardized instrument

37 Maternal Depression Screening Recommended at these well visits: 2-4 weeks, 2 month, 4 month, 6 month Can be added to pre-visit questionnaire: Edinburgh Postnatal Depression Scale (EPDS) Patient Health Questionnaire- 9 (PHQ-9) Screener

38 Maternal Depression Screening CPT: Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument. Effective 1/1/2017 Replaced 99420

39 Other EPSDT Opportunities: Adolescent Counseling Yearly ages CPT (use for MS EPSDT only as CPT does not allow to be billed with well visit) $33.62 on DOM fee schedule

40 ADOLESCENT COUNSELING Name: Medicaid ID #: Check the appropriate age for categories discussed. Check the appropriate box for areas discussed in each age group. Age 11Y 12Y 13Y 14Y 15Y 16Y 17Y 18Y 19Y 20Y CATEGORIES Reproductive Health Substance Abuse Relationships Coping Skills Wellness *Required counseling at each age Date/Counselor Date/Counselor Date/Counselor Date/Counselor Date/Counselor Date/Counselor Date/Counselor Date/Counselor I. Reproductive Health a. anatomy and physiology b. sexuality/pubertal changes c. directed abstinence based sex education d. AIDS/STDs II. Substance Abuse a. alcohol b. tobacco c. other drug (including steroids, diet pills, designer drugs, etc.) III. IV. Relationships a. parents b. physical abuse/neglect c. siblings d. peers/friends Coping Skills a. relaxation techniques b. decision making c. life planning V. Wellness a. nutrition b. exercise c. personal hygiene d. dental health e. accident prevention f. speech & hearing conservation g. cancer detection (SBE, DES)

41 Other EPSDT Opportunities Perinatal High Risk Management/Infant Services System (PHRM/ISS) Used to identify infants in their first year of life whose medical status places them at high risk for mortality and/or morbidity. Form available on DOM website with details T1023- EP can be billed twice in first year of life. $18.90 on DOM fee schedule

42 Oh, by the way Well and problem visits on same day Preventive Care Codes ( ) do not have the same key factors as other E&M codes. Comprehensive and reflect an age and gender appropriate history/exam. No chief complaint, no HPI. What about the patient s concerns or problems?

43 Oh, by the way Well and problem visits on same day If an abnormality or problem is addressed in the process of performing this service, and it is significant enough to require additional work, code an office visit also! Different diagnosis than the preventive medicine services. Use a -25 modifier with the office visit (for most payers).

44 Billing same-day well and problem visits Separate and Significant? Some considerations: Would have required return visit? Requires prescription management? Supported by separated diagnosis? If using time as a key factor: Document total time for well child visit and total time for the problem visit. Have a separate note indicating the length of time spent in counseling/coordinating care and what was discussed.

45 Issues: Billing same-day well and problem visits Might generate a co-pay. Careful consideration of E/M level. Some elements of E/M visit repeated in well visit. Most all major carriers paying. Need 2 separate notes. Can be separate documents or separated by a line or paragraph in the same document.

46 Same-day well and problem visits Well visit note: History for well visit, but no HPI for problem as it isn t pertinent to health maintenance visit. Well Physical Exam: can include abnormal findings here or document refer to problem visit exam. 1 st note impression: Well Child. Plan: anticipatory guidance, vaccines, etc. Problem visit note: HPI for problem, pertinent ROS. Exam for system of complaint/problem, or refer to well visit exam. Impression and plan for problem.

47 Resources

48 Coding Resources

49 AAP.ORG - Professional Resources/Practice Support Achieving Bright Futures Lists all codes for each individual recommended well visit Needs some updating, can refer to fact sheet above AAP Pediatric Coding Newsletter Coding for Pediatrics CME events Bright Futures Coding Fact Sheet Updated CPT and ICD-10 codes for well visits

50 Education in Quality Improvement for Pediatric Practice (EQIPP) EQIPP Bright Futures, an online learning program, weaves improvement principles and concepts with pediatric-specific clinical content to improve health outcomes. It is designed to identify and continuously close gaps in practice using practical tools. EQIPP Bright Futures courses are currently undergoing revision. It is expected to re-launch within 6 12 months. EQIPP participants simultaneously earn CME credit and meet MOC Program Part 4: Performance in Practice requirements. EQIPP is now a member benefit. 64

51 Web Site Resources 51

52 Core Tools: Integrated Format Previsit Questionnaires Allows healthcare provider to gather pertinent information without using valuable time asking questions Documentation Forms Enables Provider to document all pertinent information and fulfill quality measures Parent/Patient Handouts Provides Parental Education all the Bright Future Priorities for the visit

53 healthychildren.org General information related to child health and/or more specific guidance on parenting issues Information on AAP policies, guidelines, publications, and other child health resources Tips & tools Brightfutures.aap.org The Bright Futures Tool and Resource Kit also contains supplementary materials: Additional parent/patient handouts Developmental, behavioral, and psychosocial screening and assessment tools Practice management tools for preventive care Information on community resources All of Bright Futures developed materials are in the public domain brightfutures.aap.org/materials-and-tools/tool-and-resource-kit/pages/default.aspx Family Resources Web page Virginia Department of Health educational videos brightfutures.aap.org/ Healthy Child Care America Promotes cognitive, social and physical development of children in early education and child care Supports the needs of health professionals interested in promoting healthy and safe early education and child care programs Resource library (for health care and early education & child care professionals) Bright Futures Family Pocket Guide Developed by the National Family Voices Project IMPACT with input from the Bright Futures National Center Easy-to-use book designed to help families support health and wellness for their children at every age (in English and Spanish) Mississippi Medicaid Increased Primary Care Fee Schedule Mississippi EPSDT Website Maternal Depression Screening

54 Maternal Depression Screening Screening-and-Assessment-Forms.aspx Social/Emotional and Behavior Screens

55 Questions?

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