Admissions and Transitions Optimization Program. Nursing Facility and Practitioner Billing

Transcription

1 Admissions and Transitions Optimization Program Nursing Facility and Practitioner Billing November 2016

2 Contents Introduction... 4 Payment Reform... 5 Components... 5 Eligibility... 6 Long Term Care (LTC) Facility Eligibility... 6 Nevada LTC Facilities... 6 Colorado LTC Facilities... 6 Beneficiary Eligibility... 6 Eligibility Exceptions... 7 Opting Out for Residents... 8 Practitioner Eligibility... 8 Practitioner Letter of Intent... 9 Qualifying Six Conditions Facility Billing Onsite Acute Care Facility Billing Codes Nevada Only Billing Clarifications Practitioner Billing Evaluation and Management Practitioner Evaluation and Management Billing Code: Practitioner Billing Care Coordination and Engagement Practitioner Care Coordination and Engagement Billing Code Frequently Asked Questions Resident Eligibility Facility Eligibility Practitioner Eligibility Payment Reform: Practitioners Payment Reform: Facilities... 27

3 About HealthInsight Contact Your Medicare Administrative Contractor (MAC) Nevada Colorado Contact Us... 33

4 Introduction The purpose of this document is to provide participating nursing facilities and practitioners information regarding the payment reform components of the Admissions and Transitions Optimization Program Phase 2 (ATOP2). While not a comprehensive description of all billing procedures, the intent is to provide enough detail to explain the eligibility rules, clinical conditions included in ATOP2 and billing criteria. Updates will be provided periodically or can be found on our website at HealthInsight Nevada was one of seven organizations across the nation selected by the Centers for Medicare & Medicaid Services (CMS) to lead the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. The ATOP initiative tested models to improve quality of care and reduce avoidable hospitalizations. During phase 1, HealthInsight provided clinical education and supplemental staff to 24 nursing facilities in Nevada. Phase 1 focused on education and utilization of proven quality improvement methodologies, such as the INTERACT tools. Under this second phase, CMS has selected six Enhanced Care and Coordination Providers (ECCPs) to partner with long-term care (LTC) facilities and practitioners to implement and test a new payment model. Phase 2 will be implemented in a manner consistent with meeting CMS s objectives of the initiative s first phase: 1. Reduce the frequency of avoidable hospital admissions and readmissions 2. Improve resident health outcomes 3. Improve the process of transitioning between inpatient hospitals and LTC facilities 4. Reduce overall health care spending without restricting access to care or choice of provider To meet the objectives outlined by CMS, HealthInsight has partnered with InterMountain Quality Health in Colorado to incorporate 24 facilities that will participate in the payment reform model. Nevada facilities that participate in Phase 2 will continue to receive clinical interventions, in addition to the new payment model. Facilities in Colorado will participate only in the payment reform model and will not receive clinical support. The project period is March 23, 2016 October 23, Implementation of new billing rules is expected to begin December 1, 2016, and conclude September 30, Page 4

5 Payment Reform Phase 2 incorporates new payment levels aimed at making it more financially advantageous for both LTC facilities and practitioners to treat certain conditions in-house rather than admitting the resident to an acute care setting. The new payment model is designed to: 1. Financially support facility treatment of beneficiaries in their LTC, when appropriate, to minimize disruption to the beneficiary and hospital acquired infection. 2. Equalize the financial incentives for practitioners that exist between treating beneficiaries in a LTC facility compared to a hospital. 3. Increase practitioner engagement in care planning activities and encourage their participation in patient care conferences. Six qualifying conditions will be considered under the new payment reform model: Pneumonia Congestive heart failure (CHF) Skin ulcers, cellulitis Dehydration Urinary tract infection (UTI) COPD, asthma Components 1. Payments to a LTC facility under Medicare Part B for the treatment of qualifying conditions (for beneficiaries not on a covered Medicare Part A SNF stay) 2. Increased practitioner payments under Medicare Part B for the treatment of conditions onsite at the LTC facility 3. Practitioner payments under Medicare Part B for care coordination and caregiver engagement for beneficiaries in a LTC facility Page 5

6 Eligibility Long Term Care (LTC) Facility Eligibility Nevada LTC Facilities In addition to meeting CMS readiness criteria for Phase 2, LTC facilities in Nevada must have participated in the initiative during Phase 1 to be eligible to participate in Phase 2. Colorado LTC Facilities To participate in ATOP Phase 2, Colorado facilities must meet the following eligibility requirements (all Colorado facilities must also meet the same CMS readiness criteria as Nevada facilities): Regulatory and Demographic Criteria: (Facility status as of August 27, 2015) 1. Have a total average daily census of more than 80 residents with greater than 40 percent of the total LTC facility census as long-stay Medicare FFS 2. Have at least a three-star overall rating on Nursing Home Compare on the date of CMS s Funding Opportunity Announcement (Aug. 27, 2015) 3. Not be on the CMS list of Special Focus Facilities 4. Not had any sanctions, indictments, probations, corrective action plans or judgments imposed in the last three years relating to fraudulent or abusive billing practices 5. Be Medicare and Medicaid certified and not excluded from participation in these programs 6. Have had no survey deficiencies for immediate jeopardy to resident health or safety within the last 12 months 7. Preference will be given to those facilities using technology to support clinical care and interoperable with health information exchange Beneficiary Eligibility The payment reform model and its new billing codes can only be applied to eligible beneficiaries. The eligible beneficiary population for this Initiative is defined as beneficiaries who meet the following criteria: 1. Have resided in the LTC facility for 101 cumulative days or more starting from the resident s date of admission to the LTC facility 2. Enrolled in Medicare (Part A and Part B FFS) and Medicaid, or Medicare (Part A and Part B FFS) only Page 6

7 3. Have not opted-out of participating in the initiative 4. Reside in a Medicare or Medicaid certified LTC facility bed 5. Are NOT enrolled in a Medicare managed care plan (e.g., Medicare Advantage) 6. Have not elected Medicare hospice A resident WILL likely qualify for Phase 2 payment if: Starting from the resident s first date of admission to your facility, has he/she been in your facility at least 101 cumulative days? Is the resident enrolled in Medicare Part A and Part B FFS? Is the resident in a Medicareor Medicaidcertified bed? A resident WILL NOT qualify for Phase 2 payment if: The resident is enrolled in a Medicare Advantage plan, Medicare through Railroad Retirement, Medicare Hospice Benefit or The resident has not been in your facility for 101 cumulative days or has been out of the facility for more than 60 days. The resident is not enrolled in Medicare Part B. The resident is not in a Medicareor Medicaidcertified bed. The resident is not eligible to participate in ATOP Phase 2 if they have opted out. Eligibility Exceptions Starting from the resident s date of admission to the facility, has she/he been in the facility for 101 cumulative days? Page 7

8 If resident was enrolled in a Medicare Advantage Plan, then opted out and has Medicare A/B, those days previously enrolled in the plan in your facility do count toward the total 101 cumulative days. If resident was enrolled in Medicare Hospice, those days do not count toward the total 101 cumulative days. If resident is out of the facility for more than 60 consecutive days, total cumulative days begin at readmission. Opting Out for Residents Each potentially eligible resident is given the choice to opt out of participating in ATOP Phase 2. This form is produced by HealthInsight and is distributed to all eligible residents according to established processes. Delivery of this form to the eligible beneficiary or their power of attorney is documented. Facilities and practitioners who provide services to residents who opt out of participation in ATOP2 may not bill the new payment reform model codes. Practitioner Eligibility In order for practitioners (i.e., MD, NP, PA) to participate, they must follow the below criteria: 1. Carry an average (daily census of beneficiaries) of at least seven long-stay FFS Medicare residents (routine fluctuations do not affect eligibility) over the most recent six months in an ATOP2-participating facility. o If a practitioner s daily census of beneficiaries drops below seven at any one of the facilities they are seeing ATOP2 residents, HealthInsight must be notified. CMS understands that routine fluctuations in census are normal and will approve providers for continuance in the program on a case-by-case basis. 2. Have all licensure and certification in good standing. 3. Not have had any sanctions, indictments, probations, corrective action plans, or judgments imposed in the last three years relating to fraudulent or abusive billing practices. 4. Not be excluded from participation in the Medicare or Medicaid programs. Participating practitioners must also adhere to the following for the duration of the program: 1. Meet and adhere to all criteria in the CMS Guidance to Participating Practitioners to receive payment under this initiative throughout the entire initiative. Page 8

9 2. Provide reporting requirements outlined by 42 CFR , including reporting requests by ECCP, CMS or its contractors for the purposes of oversight, monitoring or evaluation, such as requests to participate in conference calls, submit data, conduct chart reviews, conduct site visits and/or participate in surveys. 3. Commit to make the best available care decisions for beneficiaries at all times regardless of payments received through the initiative. a. There shall be no withholding of care or services in lieu of payments. As with the facility s policy and procedure requirement, the facility will transfer a beneficiary to the hospital when appropriate. 4. Partner with the ECCP on all relevant aspects of the clinical interventions. b. This includes regular communication, coordinating care, adherence to previous commitments or agreements, or any other activities that are part of the original ECCP intervention s design. 5. Exclusively apply the payment model under this initiative to the target population. 6. Use an ONC-certified EHR and other health IT for care planning and the creation and exchange of transition of care documents. 7. Promptly communicate any changes in the LTC facility s information to the ECCP and CMS or its contractors. 8. Participate in this initiative throughout the duration (September 2020). 9. Participate with the learning community established for this initiative. 10. Execute a participation agreement with the ECCP as a partner prior to passing the readiness review and receiving payment under this initiative. 11. Accept the Medicare waivers in the cooperative agreement. Practitioner Letter of Intent As part of the application process, practitioners submit a letter of intent to participate. The letter of intent is a nonbinding agreement. All practitioners must be vetted and approved for participation in ATOP Phase 2 by CMS before the new payment structure is implemented. If the responsible billing party is unsure of a resident s status in ATOP2, please reach out to: Nevada HealthInsight Colorado Intermountain Quality Innovations (ImQI) Page 9

10 Qualifying Six Conditions According to CMS, the six conditions included in this payment reform initiative are linked to approximately 80 percent of potentially avoidable hospitalizations among nursing facility residents nationally: Urinary Tract Congestive Skin Ulcers, Pneumonia Dehydration COPD, Asthma Infection Heart Failure Cellulitis 32.8% 14.2% 11.6% 10.3% 6.5% 4.9% Below is a detailed description of the clinical criteria for each condition s clinical diagnosis. Also included are the symptomatic guidance, treatment and maximum benefit period for each. Acute Care Pneumonia LTC Facility Clinical Criteria Qualifying Diagnosis: Chest x-ray confirmation of a new pulmonary infiltrate; or Two or more of the following: o Fever >100 o F (oral) or two degrees above baseline o Blood Oxygen saturation level below 92% on room air or on usual O2 settings in patients with chronic oxygen requirements. o Respiratory rate above 24 breaths/minute o Evidence of focal pulmonary consolidation on exam, including rales, rhonchi, decreased breathe sounds or dullness to percussion Symptomatic guidance: Productive cough, increased functional decline, increase dependence in ADLS, reduced oral intake, or increased lethargy, altered mental status, dyspnea Treatment: Antibiotic therapy (oral or parenteral), hydration (oral, sc or IV), oxygen therapy and/or bronchodilator treatments. Additional nursing supervision for symptom assessment and management (vital sign monitoring, lab/diagnostic test coordination and reporting) Maximum Benefit Period: 7 days Page 10

11 Acute care congestive heart failure (CHF) LTC Facility Clinical Criteria Qualifying Diagnosis: Chest x-ray confirmation of a new pulmonary congestion, or Two or more of the following: o Blood Oxygen saturation level below 92% on room air or on usual O2 settings in patients with chronic oxygen requirements. o New or worsening pulmonary rales o New or worsening edema o New or increased jugular-venous distension o BNP > 300 Symptomatic Guidance: Acute onset of dyspnea (shortness of breath), orthopnea (SOB when lying down), paroxysmal nocturnal dyspnea (SOB waking the patient at night), new or increased leg or presacral edema, and/or unexpected weight gain. Treatment: Increased diuretic therapy, obtain EKG to rule out cardiac ischemia or arrhythmias such as atrial fibrillation that could precipitate heart failure, vital sign or cardiac monitoring every shift, daily weights, oxygen therapy, low salt diet, and review of medications, including beta-blockers, ACE inhibitors, ARBS, aspirin, spironolactone, and statins, monitoring renal function, laboratory and radiologic monitoring. If new diagnosis, additional tests may be needed to detect cause. Maximum Benefit Period 7 days Acute care chronic obstructive pulmonary disease (COPD)/asthma LTC Facility Clinical Criteria Qualifying Diagnosis: Known diagnosis of COPD/Asthma or CXR showing COPD with hyper inflated lungs and no infiltrates AND TWO or more of the following: Symptoms of wheezing, shortness of breath, or increased sputum production Blood Oxygen saturation level below 92% on room air or on usual O2 settings in patients with chronic oxygen requirements Acute reduction in Peak Flow or FEV1 on spirometry Respiratory rate > 24 breaths/minute Treatment: Increased Bronchodilator therapy, usually with a nebulizer, IV or oral steroids, oxygen, and sometimes antibiotics. Maximum Benefit Period: 7 days Page 11

12 Skin Infection (Skin Ulcers and Cellultis) LTC Facility Clinical Criteria Skin Infection Qualifying Diagnosis: New onset of painful, warm and/or swollen/indurated skin infection requiring oral or parenteral antibiotic therapy If associated with a skin ulcer or wound there is an acute change in condition with signs of infection such as purulence, exudate, fever, new onset of pain, and/or induration. Treatment: Frequent turning, nutritional assessment and/or supplementation, at least daily wound inspection and/or periodic wound debridement, cleansing, dressing changes, and antibiotics (oral or parenteral). Maximum Benefit Period: 7 days Acute care fluid or electrolyte disorder or dehydration LTC Facility Clinical Criteria Fluid or Electrolyte Disorder, or Dehydration Qualifying Diagnosis: Any acute change in condition AND TWO or more of the following: Reduced urine output in 24 hours or reduced oral intake by approximately 25% or more of average intake for 3 consecutive days New onset of Systolic BP < 100 mm Hg (Lying, sitting or standing) 20% increase in Blood Urea nitrogen (e.g. from 20 to 24) OR 20% increase in Serum Creatinine (e.g. from 1.0 to 1.2) sodium > 145 or < 135 Orthostatic drop in systolic BP of 20 mmhg or more going from supine to sitting or standing. Treatment: Parenteral (IV or clysis) fluids, lab/diagnostic test coordination and reporting, and careful evaluation for the underlying cause, including assessment of oral intake, medications (diuretics or renal toxins), infection, shock, heart failure and kidney failure. Maximum Benefit Period: 5 days Acute care urinary tract infection (UTI) LTC Facility Clinical Criteria Urinary Tract Infection Qualifying Diagnosis: Page 12

13 Acute care urinary tract infection (UTI) >100,000 colonies of bacteria growing in the urine with no more than 2 species of microorganisms. AND ONE or more of the following: Fever > 100 o F (oral) or two degrees above baseline Peripheral WBC count > 14,000. Symptoms of: dysuria, new or increased urinary frequency, new or increased urinary incontinence, altered mental status, gross hematuria, or acute costovertebral angle pain or tenderness Symptomatic Guidance: Dysuria, frequency, new incontinence, altered mental status, hematuria, CVA tenderness. Treatment: Oral or parenteral antibiotics, lab/diagnostic test coordination and reporting, monitoring and management of urinary frequency, incontinence, agitation and other adverse effects. Maximum Benefit Period: 7 days Page 13

14 Facility Billing The payment model will only provide payment to LTC facilities for the specified increased services to treat the identified six conditions. The new payment is a Medicare Part B payment. Medicaid Nursing Facility Daily Rate Allowable Medicare Part D Payment Allowable Medicare Part B Payment New Medicare Part B Payment Total Facility Payment Per Day Onsite Acute Care Payment to the facility is subject to the following conditions: Qualifying Criteria: Each of the six conditions has qualifying criteria defining the clinical or diagnostic conditions of a beneficiary that could trigger the benefit Confirmation of the qualifying diagnosis and the prescription of treatment by an attending practitioner must be confirmed by the end of the second day after an acute change in condition o An MD, DO, NP or PA must confirm the qualifying diagnosis through an in-person evaluation or qualifying telemedicine assessment o The evaluation must be documented in the resident s medical record Important: A facility may not bill unless the diagnosis has been confirmed. Duration of Benefit: a specific duration of benefit for each of the six conditions is applied in the model o If the condition continues beyond this initial duration of benefit, another assessment is required to continue billing. Limitation of Benefit: None of these codes may be billed more than once a day for a single beneficiary AND no more than one of these codes may be billed in a day for a single beneficiary, even if that beneficiary has more than one of the six conditions being treated in the facility Page 14

15 Condition Pneumonia Congestive heart failure COPD/ asthma Skin infection Fluid or electrolyte disorder/ dehydration Urinary tract infection Facility Billing Codes Billing Code G9679 G9680 G9681 G9682 G9683 G9684 Maximum Benefit Period 7 Days 7 Days 7 Days 7 Days 5 Days 7 Days The new billing codes may be applied exclusively to ATOP2-participating eligible beneficiaries for one of the six specified conditions. Payment for this billing code is $218 per day. Twenty percent beneficiary co-insurance or payment of a deductible under the model is waived. 1. The in-person practitioner evaluation is a separately billable service and not included in the Onsite Acute Care payment. This evaluation does not have to be performed by an eligible (ATOP2-participating) practitioner. 2. The LTC facility may also need to complete a Minimum Data Set (MDS) assessment for a significant change in condition (not included in the Onsite Acute Care payment). Note: The confirmation by the practitioner is not included in the Onsite Acute Care payment. A facility may bill from the first day of a change in condition, if the evaluation occurs by the end of the second day. This can be retroactive. Nevada Only ECCP practitioners (e.g. NPs that are ATOP2 clinical staff) may conduct the visit to confirm the diagnosis to qualify the LTC facility for payment. In this case, Medicare is not billed (consistent with the terms and conditions of the Initiative), but ECCPs are required to provide comparable information to CMS in lieu of a claim. Billing Clarifications The below guidance provides updates and clarifications from the Funding Opportunity Announcement (FOA) issued on August 27, 2015 which can be found at Page 15

16 Coordination/Medicare-Medicaid-Coordination- Office/Downloads/NFInitiativePhaseTwoFOA.PDF Separately-billable services under Medicare can still be billed during a benefit period. This applies to any Medicare services that can currently be billed above and beyond a Part A per diem or when a resident s stay is not covered under Part A. The facility may bill for acute care services whenever an in-person evaluation at the facility leads to a qualifying diagnosis, regardless of whether the practitioner also bills Medicare. Rules relating to duration of benefit period: to the extent that qualifying diagnoses change during a benefit period, the original benefit period should be discontinued and a new one would begin. o For example, if a resident is diagnosed with both COPD and Cellulitis on October 1, then on October 4 an assessment indicates that cellulitis has resolved but COPD hasn t, then a new seven-day period would begin for the COPD-only diagnosis on October 4. The facility could then bill through October 10, if appropriate, without an additional follow-up assessment, as long as services are medically necessary. Medicaid Nursing Facility Daily Rate Allowable Medicare Part D Payment Allowable Medicare Part B Payment New Medicare Part B Payment Total Facility Payment Per Day Page 16

17 Evaluation and Management Practitioner Billing The practitioner fee schedule has been modified for an initial visit to treat an acute change in condition (CIC) in a LTC facility. Only the six contemplated conditions (pneumonia, congestive heart failure, COPD/asthma, skin infection, fluid or electrolyte disorder/dehydration, and urinary tract infection) will be considered under this model. Benefit: This modification neutralizes site payment. Practitioner code G9685 is based on the same Resource Value Units (RVUs) as code (Initial Hospital Care). Nurse practitioners and physician assistants are reimbursed at 85 percent of the physician fee schedule amount. Purpose: Physician service or other qualified health care professional for the evaluation and management of a beneficiary s acute change in condition in a nursing facility. Beneficiary must meet required clinical criteria. Key Components Required: A comprehensive review of the beneficiary s history A comprehensive examination Medical decision making of moderate to high complexity. Counseling and/or coordinating care with nursing facility staff and other providers or suppliers consistent with the nature of the problem(s) and the beneficiary s and family s needs. Maximum Benefit Period: Code can be billed once per day for a single beneficiary. This code may only be used for the first visit in a LTC facility in response to an ATOP2- participating beneficiary who has experienced an acute change in condition (to confirm and treat the diagnosed condition). Subsequent visits are billable at current rates using existing codes. Note: A practitioner may bill for an initial visit to treat an acute CIC if a facility suspects one of the six targeted conditions, but upon examination, the resident is deemed not to have such a condition. Page 17

18 Practitioner Evaluation and Management Billing Code: New Acute Nursing Facility Care CPT Code G9685 Practitioner Billing Care Coordination and Engagement The care coordination and engagement billing code is designed to encourage practitioner involvement in LTC facility conferences with beneficiaries, their caregivers and the LTC facility interdisciplinary team about the following: 1. Review of the resident's history of present illness and current health status. 2. Typical outcomes, scenarios, events or prognosis for beneficiaries with similar conditions. 3. The resident s daily routine (e.g., waking time, eating preferences, other habits, etc.) to help the facility deliver person-centered care. 4. Measurable goals agreed to jointly by the resident, representative(s), caregiver(s), and the interdisciplinary care team. 5. A description of the resident's risk for hospital admission and emergency department visits and all necessary interventions to address the underlying risk factors. 6. Discussion of clinically appropriate preventive services and the facility's capabilities to treat certain conditions in house. 7. The development, updating, or confirmation of a person-centered care plan, including if possible, an interoperable electronic person centered care plan. 8. Discussion with the resident, family and/or other legally responsible individual about the resources that would be needed, and the residents ability to potentially be discharged to the community. 9. Establishment of a health care proxy where necessary. Page 18

19 Purpose: Description: Practitioner Clinical Criteria: Maximum Benefit Period: Nursing Facility Conference Participation in an onsite nursing facility conference with the resident and/or resident s representative, that is separate and distinct from an evaluation and management visit, including a physician, or other qualified health care professional and at least one member of the nursing facility interdisciplinary care team. In order to qualify for payment, the practitioner must conduct the discussion: With the beneficiary and/or individual(s) authorized to make health care decisions for the beneficiary (as appropriate) In a conference for a minimum of 25 minutes Without performing a clinical examination of the beneficiary during the discussion (this should be conducted as needed through regular operations and this session is focused on a care planning discussion) Include at least one member of the LTC facility interdisciplinary team The practitioner must also document the conversation in the beneficiary s medical chart The acute change in condition should be documented in the beneficiary s chart The code can be billed only once per year. Exception: the code can also be billed within 14 days of a significant change in condition that increases the likelihood of a hospital admission, even if the code had already been billed less than one year previously. In this case, a Significant Change in Status Assessment is required. As with the first component of the payment model, CMS intends to waive any requirement for a 20 percent beneficiary coinsurance or payment of a deductible under the model. Benefit: Code G9686 is based on the same RVUs as code (Office or other outpatient visit for established patient). Nurse practitioners and physician assistants are reimbursed at 85 percent of the physician fee schedule amount. In order to bill for this service, the practitioner must conduct the discussion: 1. With the beneficiary and/or individual(s) authorized to make health care decisions for the beneficiary (as appropriate) 2. In a conference for a minimum of 25 minutes Page 19

20 3. Without performing a clinical examination of the beneficiary during the discussion (this should be conducted as needed through regular operations, and this session is focused on a care planning discussion) 4. With at least one member of the LTC facility interdisciplinary team 5. The practitioner must also document the conversation in the beneficiary s medical chart. This documentation should include information on the above requirements of the conversation. Where possible, the documentation should be created electronically in the LTC facility s EHR and electronically exchanged with the practitioner and other members of the interdisciplinary team. This code may be billed: Once per year per beneficiary unless the beneficiary experiences a significant CIC Within 14 days of a significant CIC that increases the likelihood of a hospital admission Must be documented in the chart and reflected in a comprehensive MDS assessment If code G9686 is billed a second time within a year, a MDS assessment for a significant change in condition is required, and a KX modifier must be added to the claim. Practitioner Care Coordination and Engagement Billing Code New Nursing Facility Conference CPT Code G9686 Page 20

21 Frequently Asked Questions Resident Eligibility Q: Are residents who are enrolled in ATOP1 as of Sept. 30, 2016, but not been at the facility for at least 101 days eligible for ATOP2? Yes and no. These residents are eligible for the ECCP clinical interventions until discharged but are not eligible for payment reform until they have met the 101 cumulative days rule. Q: Does the 101 cumulative days rule include stays in other facilities (participating, eligible or otherwise), or does it only include the time spent in that particular participating facility? No. Should an eligible beneficiary transfer to another facility participating in the initiative, the individual would not be eligible until 101 days from the date he or she is admitted to the new facility. Q: Will HealthInsight develop and provide waivers for beneficiaries to indicate consent to participate? HealthInsight will provide opt-in resident consent forms. Q: If the resident has been to the hospital within their 101-day stay, are they disqualified? It depends on how many days elapse before the resident is readmitted to the LTC facility. It is not required that the resident be in the facility for 101 consecutive days. However, gaps of 60 days or more are not permitted. If a former resident is readmitted 60 days or more after the previous discharge, the resident will not be eligible until an additional 101 days has passed. Q: Why are residents with Medicaid pending no longer eligible? The facility is able to bill retroactively for these services and does not include those that are spending down (i.e. private pay status). The resident must have Medicare Parts A and B, and need to have been in a facility for at least 101 days to be eligible for ATOP2. Q: Are VA residents still included in the initiative? Yes, if they meet the eligibility rules as provided by CMS: Have resided in the LTC facility for 101 cumulative days or more starting from the resident s date of admission to the LTC facility Enrolled in Medicare (Part A and Part B FFS) and Medicaid, or Medicare (Part A and Part B FFS) only Have not opted out of participating in the initiative Reside in a Medicare- or Medicaid-certified LTC facility bed Are not enrolled in a Medicare managed care plan (e.g. Medicare Advantage) Q: Can ATOP staff still follow LTC residents who have been in facility less than 101 days? This would support the ATOP initiative to reduce unnecessary transfers to the hospital. New residents enrolled into the ATOP program after Sept. 30, 2016 will need to meet the Page 21

22 criteria defined by CMS, including having resided in the LTC facility for 101 cumulative days or more starting from the resident s date of admission to the LTC facility. Residents enrolled in ATOP on or before Sept. 30, 2016 can continue to be included in the clinical intervention efforts but will not be eligible for payment reform until they have met the 101-day requirement. Q: In a facility with dual SNF/LTC beds what if a resident is admitted as SNF and then transitions to LTC when does the 101-day clock start? At the time of admission to the facility or at the time they were transitioned to LTC? The 101 days begins on the day the individual is admitted to the facility. If he or she was in a SNF Part A bed, those days will count toward the 101-day threshold. Facility Eligibility Q: Can multiple LTC facilities on the same campus that are under the same ownership and management be treated as one for purposes of determining eligibility? This is currently pending determination by CMS. Q: In the facility eligibility rule 40 percent of the total LTC facility census as long-stay Medicare enrollees in traditional FFS Medicare (not enrolled in Medicare Advantage) is the long-stay Medicare enrollee percentage those who are in a long-stay bed or those who have been in the facility 101+ days? Per the Funding Opportunity Announcement, it is the percentage of those who have been in the facility for 101+ days. Practitioner Eligibility Q: Should we read the eligibility literally that practitioners are only eligible in the facilities where their load is 7+ ECCP enrolled residents in that facility? Yes, practitioners need to have a caseload of seven or more long-stay FFS beneficiaries over the previous six months in the specific facility in order to be eligible to bill under this program for services provided to ATOP residents in that facility. Q: If a practitioner does not have 7+ ECCP enrolled residents in any one facility, but they do if multiple participating facilities are added together are they eligible? No, a practitioner has to have seven residents in each participating facility. Q: A practitioner s average caseload in the facility was nine over the last six months. The figure of nine includes three short-stay patients and six long-stay residents. Does the practitioner qualify for the payment reform initiative? No, the average caseload must be at least seven long-stay patients. Q: Is the eligibility based on practice or practitioner? We have a couple of groups that may have more than seven residents in a facility but their individual practitioners do not. Page 22

23 Eligibility is based on practitioner. Q: A practitioner s total long-stay resident caseload for the prior six months was 39, yielding an average resident caseload per month of 6.5. Does the practitioner qualify for the payment reform initiative? No, this practitioner would not qualify. The average resident caseload across the six-month period must be seven or more. Q: What if a practitioner has 15 residents at one eligible facility and five at another facility? Can they bill for services at both facilities? No, the practitioner can only bill at a facility that is participating in the initiative AND where they meet the seven-resident criteria. Q: If a practitioner sees residents at more than one facility, does he have to maintain an average of seven residents at each facility or just one total? The average caseload must be seven residents per facility. Nevertheless, we recognize that a caseload may fluctuate throughout the period of performance, and CMS will address these fluctuations on a case-by-case basis. Q: What if a patient is considered long-stay (101+ days) as of March, but in fact was admitted in January and was seen by the same practitioner from admission? Does this resident count in the practitioner s January and February resident count or is the resident not counted until March when she became long-stay? The patient may be considered long-stay for the entire duration. Q: A provider s patient caseload is changing daily due to admissions and discharges. Because this is not a static number throughout a calendar month, how will this be viewed regarding billing submissions? Routine fluctuations in caseload would not affect practitioner eligibility. We would only ask ECCPs and NFs to notify CMS if there are major declines in a practitioner s caseload beyond routine fluctuations. Regardless, ECCPs should verify that each practitioner s caseload meets the initiative s requirements at least once per year. Q: If a practitioner is hired and salaried by a facility as an employee as of July 2016, and the practitioner is responsible for 50 long-stay residents every day, does the practitioner still have to wait six months until January 2017 to participate? In theory, if the practitioner had an average caseload of 14 long-stay residents for three months (July-September) and zero residents for the previous three months (April-June) resulting in an average of seven for the six months combined the practitioner could be eligible in October However, the practitioner would still need to be vetted and approved by CMS. Q: How does CMS expect participating facilities to determine when a resident is considered to be part of a practitioner s caseload for the purposes of participating in the payment reform initiative? Is it up to the facility to make that determination? Is it based on chart documentation? Generally, CMS expects each practitioner to be able to demonstrate a treatment relationship with at least seven residents over time. This relationship may be documented Page 23

24 in the residents chart, recorded via notes or lab orders, or listed as billing for services provided to the resident. It will be incumbent upon the facilities and practitioners to attest that the practitioners have an established caseload of residents, even if the practitioner is not formally listed as the practitioner of record. A resident may count toward more than one practitioner s required seven long-stay FFS beneficiaries. Q: In some facilities, the physician of record is the facility medical director. However, the medical director may not actually see any of the patients. Because the medical director is the officially listed person, is there a way to prove or show that other physicians may actually carry a caseload of seven or more patients as they re all attributed to the medical director? See response to previous question. Q: In many facilities, when a PA or NP treats a patient, the chart/responsibility is actually accredited to the patient s physician and not to the NP or PA. For the purposes of this initiative, how can the NPs and PAs be included if all official records attribute care to the physician? See response to previous question. Q: How do we enroll a large provider group who all see the same patients and may not be listed as separate patient caseloads? How can they bill for the certification visit? Residents may count toward more than one practitioner s caseload. However, practitioners are enrolled on an individual level and provider eligibility will be tracked by NPI, not by group. Q: Is a separate, facility-specific provider letter of intent (LOI) needed if an eligible provider works at several buildings and meets all of the eligibility criteria? A single LOI is acceptable as long as the LOI identifies the facilities at which the practitioner is eligible. Q: Does a practitioner s participation in Phase Two of the NFI qualify as an Alternative Payment Model (APM) as that term is used in the Medicare Access and CHIP Reauthorization Act (MACRA)? NFI is not an eligible APM for the purposes of MACRA requirements. Q: Is the ECCP and/or facility required to monitor dates of licensure and report them to the CMS Operations Subcontractor (OSC)? If a practitioner s license is scheduled to expire in the upcoming month, is the ECCP expected to alert the practitioner, facility, CMS or the OSC? There is no requirement or expectation. CMS conducts routine licensing checks on all providers. However, if ECCP staff becomes aware of any licensing issues during the initiative, ECCP should discuss with CMS. Page 24

25 Payment Reform: Practitioners Q: Are telemedicine services allowed for the physician assessment or care conference if all other criteria are met? Per CMS, regular Medicare rules and restrictions around telemedicine and billing apply. Note that ECCP practitioners (in Group B) may not receive the practitioner payment while working on this initiative. Q: The practitioner has the ability to perform a telemedicine visit; is the reimbursement the same for a telemedicine visit (assuming documentation of this visit is completed)? Yes, standard CMS rules for telemedicine would still apply. Q: Given the complex clinical conditions of many of the residents in our facility, we expect that we may need to have a Nursing Facility Conference frequently for some of these residents (for example, if there are six hospital transfers within a six-month period, we would want to have the conference at least six times). Please confirm that, assuming all documentation requirements are met, this would be permissible. The conference code may be billed only once per year in the absence of a significant change in condition. The code can also be billed within 14 days of a significant change in condition, which should be documented in the beneficiary s chart. In this case, a MDS assessment for a significant change in condition is required, and a KX modifier must be added to the claim. Q: If an approved practitioner sees a resident for a change in condition and it is confirmed to be a qualifying condition, then later that day sees the resident and family with a LTC staff member for a care coordination conference lasting at least 25 minutes, can they bill both codes in the same day? Yes. Q: What information must be documented in order for a provider to bill for a care conference? The practitioner must document the conversation in the beneficiary s medical chart. This documentation should include information on the CMS requirements of the conversation: Hold the discussion with the beneficiary and/or individual(s) authorized to make health care decisions for the beneficiary (as appropriate) In a conference for a minimum of 25 minutes Without performing a clinical examination of the beneficiary during the discussion (this should be conducted as needed through regular operations; this session is focused on a care-planning discussion) With at least one member of the LTC facility interdisciplinary team Where possible, the documentation could be created electronically in the LTC facility s EHR and electronically exchanged with the practitioner and other members of the interdisciplinary team Q: If a practitioner who is not eligible covers for one who is eligible, can he or she bill via payment reform rules? No, only practitioners who are eligible and have signed a letter of intent will be Page 25

26 permitted to bill (any other practitioner who tries to bill will automatically have his or her claim rejected). Q: Can the primary provider bill for a service ATOP practitioners (APRN or PA) in Nevada recommend after assessing a resident? No. The ATOP practitioners can do the assessment and recommend treatment, but the primary care provider still must come in and see the resident. Q: If a non-physician provider (NP or PA) is not listed as the provider or record, but they work with an enrolled physician, can that NP bill if completing the certification visit on behalf of the physician? Approved practitioners will be identified by NPI. Only claims submitted by approved NPIs will be paid. Q: Would a medical resident be able to bill if under the supervision of an enrolled provider? They may not have a caseload of patients assigned to them. Approved practitioners will be identified by NPI. Only claims submitted by approved NPIs will be paid. Q: Can a separate corporation within a nursing home chain that has NPs bill for the confirmation and care conferences? If the NP within this separate corporation is currently billing for the services they provide in a nursing home, does this trump that billing? Providers may not bill twice for the same service. Only participating providers (as identified by NPI) are permitted to bill the new codes. Q: The 2017 Medicare Physician Fee Schedule (PFS) notice of proposed rulemaking (NPRM) is expected to be released in late June or early July, finalized on or about Nov. 1, 2016 and go into effect Jan. 1, We understand that the new code numbers and policies associated with the Nursing Facility Initiative (NFI) will be included in the 2017 PFS NPRM. Given the effective date for new billing under the NFI is Oct. 1, 2016, how does CMS plan to ensure practitioners and SNFs participating in the NFI will be able to start billing under the newly established codes as of Oct. 1, 2016? Will CMS issue a One-Time Notification (OTN) to the relevant carriers to make them aware of the new codes that will become effective as of Oct. 1, 2016? If so, when will that OTN be issued? The codes and instructions will be released in October as part of the quarterly update to the PFS. Q: What are the documentation requirements for the new practitioner s Acute Nursing Facility Care code? Are they the same as the requirements for an initial SNF visit of high complexity or a follow-up? The new code essentially substitutes for CPT code and the same documentations requirements would generally apply. The patient record should either reflect a diagnosis of one of the six targeted conditions, or state that one (or more) of the six conditions was suspected, considered or ruled out. Per the FOA: Also, a practitioner may bill for the acute nursing facility care service even if the service is furnished because a LTC facility suspects that a beneficiary has one of the six targeted conditions, but upon examination it turns out that the beneficiary does not have such a condition. Page 26

27 Q: Will the provider be required to provide specific data when triggering the billing code? No, the provider would bill the same way they bill all other Medicare FFS claims. However, there will be separate requirements for providers to submit other data to CMS (via the ECCP) pertaining to demonstration activities on a regular basis; further information on data submission requirements will follow at a later date. Payment Reform: Facilities Q: If an attending practitioner does not agree to participate, will the facility be able to bill for services provided? Yes, as long as a practitioner has performed the initial assessment required for billing. Q: What is the waiting period between occurrences of one of the six eligible conditions? There is no requirement for a gap between benefits if the qualifying criteria persist after seven days. However, a practitioner reassessment will be required. Q: If the facility is receiving Medicare Part A payment for a resident and the patient develops pneumonia, can the facility still bill for the services? Only if they are enrolled in Medicare Part B and have met the other eligibility criteria. Note that typically the resident is not long-stay if the facility is still being paid by Medicare Part A. If the resident is on a part A SNF stay, facilities cannot bill the ATOP2 code. Q: Is the payment model supplemental or part of the actual scheduled payment facilities currently receive? The facility payment received under this initiative is in addition to any payments currently received. Q: How does the facility need to document the qualifying diagnosis? There must be documentation in the medical records of the assessment. Q: If a resident meets the criteria for two or more of the conditions, only one at a time would be paid, correct? For example, pneumonia is identified, then on day three, dehydration is identified. The pneumonia resolves on day five, but the dehydration continues until day eight. Would the facility bill for pneumonia days one-five and then dehydration days six-eight? Facilities can only bill one condition payment per day. They would not be able to bill both pneumonia and dehydration at the same time. On day six, in order to bill for dehydration, a practitioner would need to do the initial assessment before the dehydration could be billed. Q: After the qualifying visit, the building can begin to bill the code for the eligible number of days. What data transfer is required and how is the data transferred (via the ECCP or directly to CMS)? The facility would submit a claim to Medicare just like any other Medicare Part B claim. Separately, we will be collecting data on each use of the new billing code as well as other Page 27

28 information CMS needs to monitor the initiative. We currently expect that ECCPs will collect data from all participants and submit data to the CMS Operational Support Contractor on a quarterly basis. Q: Are there any additional data collection expectations for the practitioner when the payment code is triggered? Practitioners are not responsible for collecting or submitting data relating to facility billing. We currently plan to collect data from practitioners only for the care conference visits. Q: What are the documentation requirements for the detection of acute change of condition? By what type of health care professional (e.g., LPN, RN, CNA)? Does the documentation need to be noted in the medical record? If the documentation needs to be in the medical record, what formats are acceptable (e.g., STOP AND WATCH tool, SBAR, free text note, structured clinical documentation)? Documentation must be noted in the medical record. Any of the above format would be acceptable as long as they are part of the medical records. We expect that the notation would be made by a physician or a nurse at the LPN level or higher. Q: If there is more than one qualifying diagnosis, should both be reported even if it doesn t make a difference regarding the payment to facility/provider? Yes. Q: Can the ATOP practitioner (APRN or PA) in Nevada conduct the visit to confirm the diagnosis to qualify the LTC facility for payment? Yes. Q: Is it correct that regardless of a practitioner s participation in Phase Two, they can still provide a confirming diagnosis to initiate facility payment? Must the practitioner be the resident s physician of record or can this be someone that the home designates to conduct the confirming diagnosis? Any attending practitioner can provide the confirming diagnosis for the purposes of facility payment. Q: Will a provider, who is not enrolled or eligible in the project, be required to complete training to be informed and to comply with requirements for certification for the facility to be eligible to bill for services? No, facilities are free to make whatever arrangements they deem appropriate to obtain a confirming diagnosis. Q: What does the flow chart look like? Does the facility have to raise a flag first that the six conditions are being considered, starting the two-day clock? A: Could every acute change in condition visit be billed under this new code? That s not the intent, but you could argue that one of the six conditions could be on the differential for a whole range of chief complaints. B: If the provider is in the building when the change is noted and the nurse taps the doctor on the shoulder to see the patient, there wouldn t be a paper trail in that case of the facility alerting the provider it might be one of the six conditions, etc. The facility may not bill unless the diagnosis has been confirmed. If treatment for the Page 28