3/28/2016. Evaluation and Management. Evaluation and Management Emerging Trends. Disclosures. Evaluation and Management The History

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1 Evaluation and Management Emerging Trends Peter Hollmann MD Past CPT Panel Chair Disclosures Ambassador for AMA CPT Member RBRVS Update Committee 2 Evaluation and Management The History Evaluation and Management Created for CPT 1992 CPT E/M Guidelines, Preventive Medicine Codes also HCFA Documentation Guidelines 1997 HCFA Documentation Guidelines E/M Workgroup Rise of Electronic Records Recognition Non Face to Face and Team Care Care Management and PCMH Medical Decision Making E/M - The reality 2012 PFS Proposed Rule (July 2011) 2010 total Part B spend $110B 2010 Part B on E/M $33.5B A substantial portion of surgical procedures is unreported E/M Actual post op visits or similar services in pre/post time Used by all specialties (almost) and non physician professionals Due to budget neutrality any change in E/M will be paid for from E/M Intra-specialty consistency vs. inter-specialty consistency Fundamental structure is single problem focused H+P the Medical Student Approach to Coding 5 6 1

2 Professional Response Meet with CMS to better understand request and educate Recognize established codes (e.g., warfarin management) Recognize monthly fee for PCMH CPT/RUC will create/value codes that address non F2F time and care management Discussed only and not proposed Revise E/M Acute care Chronic care Post op global care Goals of New Services Recognize work and practice expense of chronic care management Non F2F Electronic Records Advanced Primary Care Team care and efficient practice at the top of the license Patient/caregiver involvement Stimulate transformation of the delivery system Primary Care orientation without creating specialty specific codes 7 8 B Status CPO (other than homecare, hospice, NF) Prolonged Services Non F2F Anticoagulant Management Medical Team Conferences CPO Nursing Facility Telephone On-line Interprofessional Consultation Complex Chronic Care Management Medicare Statutory Benefit and Other E/M like Codes Welcome to Medicare Physical (G0402) Annual Wellness Visit (G0438-G0439) Preventive Services Screening/counseling (many G codes) CPO Home Care and Hospice (G0181-G0182) Certification/recertification of home care (G0179-G0180) 9 10 New Paid Services Since Proposed PFS 2012 Rule Transitional Care Management Chronic Care Management Advance Care Planning Prolonged Professional Staff Services Evolving Concepts

3 2016 PFS Proposed Rule 2016 PFS Proposed Rule PFS Proposed Rule Under Consideration Dementia Assessment Guideline driven, quality measure, E/M does not describe service adequately CCM based on Professional Time CPO when not HH or Hospice (or CCM is N/A or less favorable) Non F2F Acute Care Episodes NF and home/dom/alf Principle Care CCM CCM without two or more conditions, not PCP MTM in a physician/qhcp office Using pharmacists outside of Part D Behavioral Health Co-Management/Assistance Community Based Consult Services applied to PCMH embedded MH clinicians Unusual Complexity E/M add-on Newer Services Coding and Tips TCM CCM Advance Care Planning Prolonged Clinical Staff Services Putting Newer Codes into Practice

4 Transitional Care Management TCM - New in Final Rule TCM The Patient Required Services DISCHARGE FROM IP Acute Care Hospital IP Psychiatric Hospital LTC Hospital SNF IP Rehab Facility Hospital Outpatient OBS or Partial Hospital Partial Hospital at CMHC DISCHARGE TO Home Domiciliary Rest Home Assisted Living Facility Interactive Contact Within 2 business days: F2F, phone, Must make 2 attempt within 2 business days Certain Non Face to Face Services Necessary services for transition (eg record review, care coordination) A face to face visit Within 14 days Medication Reconciliation required by required F2F date TCM Rules 30 days (Date of Discharge is Day#1) First F2F visit is not reported separately; additional E/M may be reported Only one professional may report Not to be reported by professional who is providing services within a global period The discharge day services may not constitute the initial F2F visit May not report Certification (G0179-G0180), CPO (G0181-G0182), or ESRD ( ) TCM Code Selection

5 TCM Medical Decision Making Over the 30 day period not the initial F2F Uses E/M Guidelines to Define Level of MDM TCM- Medical Decision Making Over the 30 days TCM- Who may report and Documentation Required TCM Who may REALLY report The physician (MD/DO or qualified NP, PA, CNS, or CNM) is to oversee management and coordination of services, as needed, for all medical conditions, psychosocial needs and activity of daily living supports for the full 30 days post discharge (c.f. MPFS Final Rule, CY 2013, p. 313) TCM- Should you Report? TCM- Should you Report? CODE FEE (NF) $ $ $ $ CODE FEE (NF) CODE FEE (NF) SUM (G+G+E/M) $ G0180 $54.10 $ $ G0181 $ $ $ $ But CPO is uncommon and Certification + E/M pays less

6 TCM Resource (ICN June 2013) This publication notes billing on Day 30 Chronic Care Management Chronic Care Management Chronic Care Management TCM and CCM codes created by CPT for 2013 Medicare accepts TCM and CCM is B status 2014 Fee Schedule CMS proposes paying a single G code for CCM of 20 minutes or more in a 30 days period, for persons with 2 or more chronic conditions Lots of other issues included, eg PCMH and EMR certification and no link to a face to face service Apparent goal was high volume, low dollar payments for a large proportion of beneficiaries CPT responds with Medicare code Value $ CCM and Complex CCM CODE # Chronic Conditions >2 >2 Duration of Conditions 12 months or until death 12 months or until death Clinical Staff Time > 20 minutes > 60 minutes Period of service Calendar Month Calendar Month Comprehensive Care Plan Established, implemented, revised or monitored Established or substantial revision MDM No requirement Moderate or High Medicare Payment $40.84 B Status CCM- Who Qualifies

7 Role of Physician or QHCP CCM Services Oversees the management and/or coordination of services, as needed, for: All medical conditions, Psychosocial needs and Activities of daily living Incident to By appropriately qualified clinical staff Or personally by provider CCM Services CCM Care Plan CCM- Practice Requirements CCM Initiation and Consent

8 CCM- EMR Requirements CCM- EMR Requirements CCM- EMR Requirements CCM - Restrictions Not in an Advanced Primary Care Demonstration Project the Specific Patient Not with other Care Management Service Codes for same time period CCM Resource (ICN May 2015) Advance Care Planning

9 Advance Care Planning ( ) Advance Care Planning For CY 2016, CMS has changed assignment of CPT codes and PFS status to indicator A, (defined as: Active code). The presence of an A indicator does not mean that Medicare has made a national coverage determination regarding the service. Contractors remain responsible for local coverage decisions in the absence of a national Medicare policy. Medicare allowance is $85.99 and $74.88 for and respectively Advance Care Plan 2016 Final Rule 2016 Final Rule Separately payable with AWV; use modifier -33 so beneficiary has no cost sharing If done with AWV can also be a team service Also separately payable with E/M; use modifier -25 on E/M (does not include Critical Care) CMS allows that the service be incident to with some significant direct supervision ACP - additional points Standard CPT Time Rules (more than ½ way to midpoint) Do not count any time that was part of determining level of E/M as ACP time Does not require execution of a legally recognized advance directive No predetermined frequency limits No specific special training/specialty restrictions Prolonged Clinical Staff Services

10 Prolonged Services: New Codes What has changed for Prolonged Services? Prolonged Service Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision New title and subsection guidelines New timed codes to identify prolonged clinical staff time of one hour (99415) and each additional half hour (99416). Reported for prolonged clinical staff services service (beyond the typical E/M service time) during an evaluation and management service Prior to 2016, codes and were the only codes that could be reported for prolonged services provided face-to-face with the patient. These services state that the physician or qualified health care professional was providing the service. The development of the new codes allows a method for reporting face-to-face services that are not provided by the physician/qhp for things that only require face-to-face observation by clinical staff under the supervision of a physician /QHP. Development of the new codes allow for such reporting under specifically noted circumstances Reporting and Prolonged Services: Example The typical face-to-face time of the primary (ie physician/qhcp) service is used in defining when prolonged services time begins Less than 45 minutes of prolonged service is not reported separately When face-to-face time is noncontiguous, use only the face-toface time provided to the patient by the clinical staff. Do not count time of CS providing other reported services (except the E/M). No more than 2 simultaneous patients Physician/QHCP must be present Do not report with physician/qhcp prolonged services codes Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family Prolonged Services: Example Total Duration of Prolonged Services Table Total Duration of Prolonged Services Code(s) Prolonged services begins AFTER 25 minutes (typical time listed in 99214) Code is not reported until at least 70 minutes total face-to-face clinical staff time has been performed Because 45 minutes of prolonged services must be performed beginning AFTER the typical time = 70 Why? less than 45 minutes minutes (45 minutes - 1 hr. 14 min.) minutes (1 hr. 15 min. - 1 hr. 44 min.) Not reported separately X X 1 AND X or more (1 hr. 45 min. or more) X 1 AND X 2 or more for each additional 30 minutes

11 Prolonged Services: Revised Codes and Guidelines Prolonged Services codes and guidelines have been revised and updated for consistency with instructions in the Psychotherapy guidelines and following code These changes: Further define that codes and are prolonged evaluation and management and psychotherapy service(s) rather than just the generic prolonged services Refer to new codes and when reporting prolonged clinical staff services Medicare Fee CODE FEE $ $