Strategies for Coding, Billing and Getting Paid Appropriately

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1 Strategies for Coding, Billing and Getting Paid Appropriately 2015 Monograph Update California Academy of Family Physicians

2 Another new year and time to make sure your practice is doing everything possible to capture the best reimbursement possible for the upcoming year and possibly get ready for some new things we expect to be covered by Medicare in the near future. It is also time to plan ahead and make sure your practice will not be on the receiving end of any monetary penalties imposed by Medicare or any other third party payer. Current Procedural Terminology (CPT)/Coding Changes for 2015 What do they mean for Family Medicine? Military History has been added to the list of elements for social history when taking a patient history. Time to update templates used in electronic health records (EHR) or patient health history forms completed by staff or patients to include all of these elements of social history: o Marital status and/or living arrangements o Current employment o Occupational history o Military history o Use of drugs, alcohol, and tobacco o Level of education o Sexual history o Other relevant social factors Maternity Care and Delivery Guidelines have been updated to clarify a visit when pregnancy is confirmed. Those guidelines now specify that pregnancy confirmation during a problem oriented or preventive visit is not considered a part of antepartum care and should be reported using an appropriate Evaluation and Management (E/M) service code for that visit. Antepartum care does include the initial prenatal history and physical examination. Advanced Care Planning has been recognized as a separate service, and there were two CPT codes developed for 2015 that are to be used when physicians counsel patients about their options for end- of- life care. While Medicare currently will not pay physicians for this service using the new CPT codes, it has said it will consider a change for 2016, giving the public ample opportunity to weigh in on the topic during Such counseling should be voluntary, aiming to make patients aware of their options so they can determine the type of care they want at the end of life. It is an idea that has wide support in the medical community, and some private insurance plans already pay for such counseling. Supporters say counseling would give patients more control and free families from torturous decisions. 2 P age

3 The new codes, and 99498, cover advance care planning including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional (QHP); face- to- face with the patient, family member(s), and/or surrogate. first 30 minutes each additional 30 minutes This service requires three basic elements: 1. A face- to- face meeting between physician/qhp and patient, family surrogate 2. Counseling and discussing advance directives the document which appoints an agent and/or recording the wishes of patients pertaining to their medical treatment at a future time should they lack decisional capability at that time 3. Completion of relevant legal forms. Note that it may be appropriate to complete the forms at the time of this visit. However, if the patient needs additional time and planning, the forms could be completed at a later date. No active management of problems is undertaken during the time period reported for Advanced Care Planning. An E/M can be reported separately on the same day as this service except for the following services: Critical Care ( ) Inpatient Neonatal & Pediatric Critical Care ( ) Initial and Continuing Intensive Care of Neonate ( ) Medicare has assigned the services a status indicator of I, which means, Not valid for Medicare purposes. Medicare uses another code for the reporting and payment of these services. Care Management Services (CMS) have been re- defined for Although this section of CPT was developed two years ago, 2015 will be the first time Medicare recognizes these services and will begin to pay for them. The American Medical Association (AMA) and the CPT panel have added some refinements for these services. Also, one code has been deleted and another has been added. CPT started by renaming these services Care Management Services instead of Complex Chronic Care Coordination Services. The section was divided into two subsections that differentiate between Complex Chronic Care Management Services and Chronic Care Management Services (CCM). One code (99488) was deleted from the Complex CCM section and one new code (99490) was added to the CCM section. 3 P age

4 Care Management Services Complex Chronic Care Management Services Chronic Care Management Services The Complex Chronic Care Management codes include all of the criteria for Chronic Care Management services plus additional criteria. All three codes are time- based, but the normal time requirements for billing do not apply. A provider must use the entire time in order to bill for the service. The codes and their abbreviated descriptions are Chronic Care Management Services Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month Required elements are Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline Comprehensive care plan established, implemented, revised, or monitoring Complex Chronic Care Management Services Complex chronic care management services, 60 minutes of clinical staff time Each additional 30 minutes of clinical staff time Required elements are 4 P age

5 Multiple (two or more) chronic conditions expected to last at least 2 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline Establishment or substantial revision of a comprehensive care plan Of note changing medications is not considered a substantial change, nor is ordering physical therapy considered a substantial change. Moderate or high complexity medical decision making 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month Here is a comparison of the required elements: Two or more chronic conditions Comprehensive care plan established, implemented, revised, or monitored Chronic conditions place patient at significant risk of death, acute exacerbation/decompensation, or functional decline Chronic Care Complex Chronic Care 99487, Establishment or substantial revision of a comprehensive care plan N/A Moderate or high complexity medical decision making Clinical staff time 20 minutes 60 minutes N/A A few more specifics about Care Management Services when provided to Medicare patients: CMS requires that the care plan be communicated to the patient either by paper or electronically and that delivery should be documented in the patient s medical record. CMS requires the billing provider to use electronic health record technology that is certified by a certifying body authorized by the National Coordinator for Health Information Technology. For 2015, that certification can be either the 2011 or 2014 certification. 5 P age

6 CMS allows either a direct employment relationship or a contracted arrangement with clinical staff providing these services under general supervision of the physician. CMS will pay only one provider to provide these services to a Medicare beneficiary during any 30- day period. If a face- to- face visit is provided during the 30- day period, the appropriate E/M service for that visit should be billed in addition to the CCM service. The practice must provide 24/7 access (not through the emergency room) to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with a health care professional in the practice to address urgent needs regardless of the time of day or day of week. Transitional Care Management (TCM) may not be billed during the same 30- day period as CCM. CPT also developed paragraphs describing the typical patient for each type of Care Management and relocated those under the new subsection headings. Remember, Care Management Services can be provided to any patient pediatric or adult. For a complete discussion of Chronic Care Management, access the CAFP January, 2015 Practice Management News. Changes to Arthrocentesis, aspiration and/or injection of the joint or bursa have been made for The three current codes for this service, 20600, 20605, and 20610, have been revised to identify this service as being performed without ultrasound guidance. Three new codes have been added to identify this service as being performed with ultrasound guidance, with permanent recording and reporting. Those new codes are for small joint or bursa (eg., fingers, toes) for intermediate joint or bursa (eg., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) for major joint or bursa (eg., shoulder, hip, knee, subacromial bursa) Remember, there must be permanent recording and reporting to support these new services. There is a difference between a diagnostic ultrasound and an ultrasound used for needle guidance, so billing a diagnostic ultrasound code for the localization is not acceptable. It would be acceptable to bill a diagnostic ultrasound in addition to the needle guidance ultrasound if there is documented medical necessity to support the need for the diagnostic ultrasound. Two vaccines expected to become available soon have been given CPT codes. They are Influenza virus vaccine, quadrivalent (IIV4, split virus, preservative free, for intradermal use Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonvalent (HPV), 3 dose schedule for intramuscular use. 6 P age

7 A new code was added for brief emotional/behavioral assessment (eg., depression inventory, attention- deficit/hyperactivity disorder [ADHD] scale, with scoring and documentation, per standardized instrument. One should continue to use CPT for developmental screening. Topical fluoride varnish application has received a new CPT code for That code is Many state Medicaid/Medi- Cal programs require that this service be provided as a preventive measure to children and especially those children receiving Child Health and Disability Prevention Program (CHDP) services. The code is intended for use only by a physician or QHP. When performed by the clinical staff, this service cannot be reported. Update your billing systems to include these CPT changes now to assure you are billing correctly. Otherwise, your claims will be returned and you will miss out on additional revenue Out with the Bonus; In with the Penalty! Physician Quality Reporting System (PQRS) 2014 was the last year to earn an incentive under PQRS. CMS will now apply a 2% Medicare payment reduction in 2017 to Eligible Providers (EPs) and group practices that do not successfully report data on PQRS quality measures in Five total individual options and nine group practice reporting options for reporting to avoid the 2017 PQRS payment adjustments have been finalized. Options for Individual EPs to Satisfactorily Report 2015 to Avoid 2017 Penalty Claims and Qualified Registry: EPs must report at least nine measures covering at least three of the National Quality Strategy (NQS) domains and report each measure for at least 50% of the EP s Medicare Part B fee- for- service (FFS) beneficiaries seen during the reporting period to which the measure applies. Direct EHR or EHR Data Submission Vendor: EPs must report at least nine measures covering three NQS domains. If an EP is unable to report on nine measures through Certified EHR Technology (CEHRT), they must report on all measures that include Medicare patient data in order to avoid the 2017 PQRS penalty. EPs are required to report Medicare patient data on at least one measure. Qualified Clinical Data Registry (QCDR): EPs must report nine measures covering three NQS domains for at least 50% of an EP s total patient population seen during the reporting period, including at least two outcomes measures as part of the required nine. If two are not available, EPs must report at least one outcome measure in addition to one of the following types of measures: resource use, patient experience of care, efficiency/appropriate use or patient safety. While CMS did not include patient safety as one of the additional types of measures for 7 P age

8 reporting in the 2015 proposed fees schedule, the agency added this category to provide EPs who do not meet the nine- measure threshold another option to successfully report. Measures Groups via a Qualified Registry: Individual EPs reporting on measures groups via a qualified registry must report at least one measures group over the 12- month reporting period. Each measures group must include at least 20 patients, the majority of which (11 patients) must be Medicare Part B FFS patients. Options for Groups of 2 99 EPs to Satisfactorily Report 2015 PQRS to Avoid 2017 Penalty: Starting in 2015, CMS modified the deadline for groups to register to participate in PQRS Group Practice Reporting Option (GPRO) from September 30 to June 30 of the reporting year. In order to register under GPRO using the Physician Value (PV)- PQRS registration system, the group practice must have an approved Individuals Authorized Access to the CMS Computer Services (IACS) account and indicate its selected reporting method for the 12- month period. GPRO- Web Interface (groups with 25+ EPs only): A group practice must report data on all measures for the first 248 consecutively assigned patients. If the pool of assigned beneficiaries is fewer than 248, the group must report on 100% of its eligible patients. Groups are required to report on at least one measure for which there is Medicare patient data. GPRO- Registry and EHR Reporting: A group practice reporting via a registry must report at least nine measures covering three NQS domains for at least 50% of its Medicare Part B FFS beneficiaries seen during the reporting period to which the measure applies. If fewer than nine measures covering three NQS domains apply to the group, it must report on 50% of the group s Medicare Part B FFS beneficiaries for each measure, up to eight measures covering between one and three NQS domains. A group reporting via an EHR must report nine measures covering at least three NQS domains or should fewer than nine measures apply, the group must report all measures to which patient data applies, with a minimum of one measure. All groups must report on at least one measure for which there is Medicare patient data. Changes to Measures Groups Starting in 2015, a minimum number of six measures must be included in a PQRS measures group, up from four in previous years. Continuing Medical Education (CME) removed four measures groups and finalized 22 reportable measures groups for For 2015 reporting, CMS removed 51 measures from the PQRS measures set. In addition, CMS finalized 19 cross- cutting measures with additional changes to the reporting mechanisms 8 P age

9 available per measure. A list of the 255 PQRS measures available in 2015 is available on the CMS website at The Complex Chronic Care Management codes include all of the criteria for Chronic Care Management services plus additional criteria. All three codes are time- based. Value- Based Payment Modifier (VBPM): Under the Affordable Care Act (ACA), the Secretary of Health and Human Services is required to apply a VBPM first to specific physicians and groups of physicians the Secretary deems appropriate and ultimately to all Medicare Part B physicians by January CMS phased- in the VBPM by first applying it to large group practices in 2015 based on 2013 reporting, then to groups with 10or more EPs in 2016 based on 2014 reporting. The agency must complete the phase- in of the VBPM by applying it to all physicians in 2017 based on 2015 reporting. The VBPM assesses both quality of care furnished and cost of providing that care under the Medicare Physician Fee Schedule (PFS). The 2017 VBPM is based on 2015 quality and cost performances. CMS estimated the VBPM will affect approximately 900,000 physicians in Calendar Year VBPM quality scores are based on 2015 PQRS reporting. CMS designated two categories of physicians for the purposes of applying the 2017 VBPM. Category 1: Includes solo practitioners who satisfactorily report PQRS quality measures as individuals and those in group practices that meet the criteria via GPRO for purposes of avoiding the 2017 PQRS payment adjustment during the 2015 reporting year. Additionally includes groups that do not self- nominate through GPRO under PQRS, but have at least 50% of EPs who meet the criteria for satisfactory reporting for PQRS as individuals. Category 2: Groups and solo practitioners who are subject to the 2017 payment adjustment but do not fall under Category 1. Quality- Tiering grants the opportunity to earn an upward payment adjustment for providing high quality, low cost care to Medicare beneficiaries as compared with national benchmarks. Conversely, it puts certain groups at risk of receiving downward payment adjustments for providing low quality, low cost care to Medicare beneficiaries. Under Category 1, CMS applies the quality- tiering methodology to all groups and solo practitioners. Groups with two to nine EPs and solo practitioners are only subject to upward or neutral adjustments and are considered immune to downward adjustments, while groups with 10 or more EPs are subject to upward, neutral or downward adjustments. Under Category 2, CMS applies a 4% downward payment adjustment to groups with 10 or more EPs and a 2% downward adjustment to groups with two to nine EPs and solo practitioners. 9 P age

10 These adjustments are made in addition to the PQRS penalties EPs receive for not successfully reporting in the program. CMS will include all 2015 PQRS quality measures and reporting mechanisms available for both individual and GPRO reporting when calculating the 2017 VBPM. Start now to educate yourself and your staff about the VBPM if you have not yet been subject to this possible penalty. Learn what you need to do NOW to avoid any further possible penalties. One More Task for The Implementation of ICD- 10 The transition to reporting diagnosis with International Classification of Disease, 10 th Revision Clinical Modification (ICD- 10- CM) is currently slated for implementation on October 1, This will be a big transition for any practice. Now is the time to begin planning, educating, and preparing for a successful and financially risk- free implementation. Brush off any implementation plans from previous years and start getting ready now. As always this year promises to be a busy year for family physicians. Take advantage of any and all new billing opportunities, but keep your eye on possible penalties and make sure you don t fall subject to any of them. 10 P age