Third Party Payer Days. IMGMA February 25, 2015

Third Party Payer Days IMGMA February 25, 2015

Agenda 2015 Medicare Physician Fee Schedule Medicare Physician Fee Schedule Database Transitional Care Management - Reminder Medicare - Coverage Guidelines Chronic Care Management New Coverage Anesthesia with Screening Colonoscopy Procedures - Clarification Medicare Part B Coverage of Pneumococcal Vaccinations - Modification 2

Presented by Joy Newby, LPN, CPC, PCS Newby Consulting, Inc. 5725 Park Plaza Court Indianapolis, IN 46220 Voice: 317.573.3960 Fax: 866.631-9310 E-mail: help@joynewby.net

This presentation was current at the time it was published and is intended to provide useful information in regard to the subject matter covered. Newby Consulting, Inc. believes the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the manual are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed. The information contained in this presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Any five-digit numeric Physician's Current Procedural Terminology, Fourth Edition (CPT) codes service descriptions, instructions, and/or guidelines are copyright 2014 (or such other date of publication of CPT as defined in the federal copyright laws) American Medical Association. For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes and service/procedure descriptions to be used in this presentation. The American Medical Association assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this publication.

2015 Medicare Fee Schedule Sustainable Growth Rate (SGR) Balance Budget Act of 1997 Beginning in 2002, the actual expenditures began to exceed the allowed targets The SGR is a formulaic approach intended to restrain the growth of Medicare spending on physician services. Scheduled for negative 21.2% update for 2015 5

2015 Medicare Fee Schedule Cont d Protecting Access to Medicare Act of 2014 Replaced the negative 21.2 % update (Up from 20.1% in 2014) with a 0% update Only for dates service 1/1/2015 3/31/2015 Original update kicks in 4/1/2015 1/1-3/31/2015 CF = $35.8013 Late adjustment to $35.7547 4/1 12/31/2015 CF = $28.2239 6

Sequestration Budget Control Act of 2011 Requires 2% payment cut for all Medicare physician claims Dates of service on or after April 1, 2013 Slated to continue until the end of 2021 Pathway for SGR Reform Act of 2013 extended the 2% payment reduction until 2023 7

Extension for Medicare Outpatient Therapy Services New caps for outpatient therapy services effective 1/1/2015 Physical therapy/speech language pathology Cap = $1,940 Occupational therapy Cap = $1,940 1103 Protecting Access to Medicare Act of 2014 extends exceptions to therapy caps through 3/31/2015 Submit the -KX modifier on therapy claims when the exception applies 8

Physical Therapy, Speech Language Pathology and Occupational Therapy Cont d 103 of the Protecting Access to Medicare Act of 2014 extended the therapy caps exceptions process through dates of service on or before March 31, 2015 A manual medical review process, as part of the therapy exceptions process, applies to therapy claims when a beneficiary s incurred expenses exceed a threshold amount of $3,700 annually for the given service, e.g., PT/SLP or OT 9

CMS Announces Proposal to Change Global Surgical Package In the 2015 Final Rule, CMS proposes to retain global bundles for surgical services, but to refine bundles by transforming over several years all 10- and 90-day global codes to 0-day global codes. Medically reasonable and necessary visits would be billed separately during the pre- and post-operative periods outside of the day of the surgical procedure. CMS is proposing to make this transition for current 10-day global codes in CY 2017 and for the current 90-day global codes in CY 2018 CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 10

Medicare Fee Schedule Database Includes more than relative value units Assists managers with the physician supervision requirements for diagnostic tests Remember, only a physician can supervise diagnostic tests Assists coders with Determining the postoperative percentage for comanaged surgical services 11

MFSDB Assists Coders Cont d Determining the number of postoperative days assigned to the code Some services in the radiology section of CPT are assigned 10-day postoperative periods. 77789 Surface application of radiation source Some services in the radiology section of CPT are assigned 90-day postoperative periods. 77761 Intracavitary radiation source application; simple CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 12

MFSDB Assists Coders Cont d Some services in the medicine section of CPT are assigned 0-day postoperative periods. 93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization 98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved Some services in the medicine section of CPT are assigned 90-day postoperative periods. 92986 Percutaneous balloon valvuloplasty; aortic valve CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 13

MFSDB Assists Coders With Cont d Multiple service pricing logic Determining whether a procedure code is unilateral or bilateral Determining whether an assistant surgeon is allowed Determining whether co-surgeons are allowed (modifier -62) Determining the base endoscopy code when multiple endoscopic procedures are involved CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 14

Transitional Care Management Covered by Medicare Transitioning patient from a facility to the patient s community setting TCM is billed for a 30-day period Begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days Date of service for CPT code is day 30 Place of service is where the face-to-face visit occurs CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 15

TCM Cont d Requires interactive contact within 2 business days after discharge from the facility Includes a provider/patient face-to-face visit within a specific number of calendar days Cannot bill Chronic Care Management during the same calendar month CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 16

TCM Transition Defined The transition in care is from: an inpatient hospital setting (acute care, rehab, LTAC) partial hospital observation status in a hospital skilled nursing facility/nursing facility To the patient s community setting: home domiciliary rest home or assisted living 17

TCM Direct Communication Interactive contact Required contact with the patient or caregiver, as appropriate, may be by the physician or qualified health care professional or licensed clinical staff. Within two business days of discharge is Monday through Friday except holidays without respect to normal practice hours or date of notification of discharge. Contact may be Direct (face-to-face) Telephonic Electronic means 18

TCM More than 1 Contact and 1 Face-to-Face Visit Physician/other qualified health care professional s non-face-to-face services may include, but are not limited to the following Obtain and review discharge information (for example, discharge summary or continuity of care documents) Review need for or follow-up on pending diagnostic tests and treatments 19

Provider s Non-Face-to-Face Cont d Interact with other health care professionals who will assume or reassume care of the beneficiary s system-specific problems Provide education to the beneficiary, family, guardian, and/or caregiver Establish or re-establish referrals and arrange for needed community resources Assist in scheduling required follow-up with community providers and services 20

TCM More than 1 Contact and 1 Face-to-Face Visit Cont d Supervision requirements for the non-face-toface services included in transitional care management (TCM) is general supervision Effective 1/1/2015 Licensed clinical staff may furnish the following non-face-to-face services: Communicate with agencies and community services used by the beneficiary 21

Licensed Clinical Staff Cont d Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living Assess and support treatment regimen adherence and medication management Identify available community and health resources Assist the beneficiary and/or family in accessing needed care and services 22

TCM Codes 99495 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 23

TCM Codes Cont d 99496 Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 24

Medicare Coverage Changes for 2015 not all inclusive Chronic Care Management Anesthesia with Screening Colonoscopy Procedures - Clarification Medicare Part B Coverage of Pneumococcal Vaccinations - Modification 25

Chronic Care Management Coverage effective 1/1/2015 Designed to pay separately for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions Not a per member/per month payment Billed based on non-face-to-face time 1 CPT code CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 26

CCM Resources CMS Fact Sheet Chronic Care Management Services ICN 909188 January 2015 Federal Register 11/13/2014 Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015 Final Rule Federal Register 12/10/2013 Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014 Final Rule 2014 CPT Copyright American Medical Association CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 27

CPT Code 99490 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, with the following required elements: 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 monitored 2015 Indiana Fee Schedule $40.70 CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 28

What Does CCM Include? Includes, but is not limited to Structured recording of patient health information An electronic care plan addressing all health issues Access to care management services 24/7 Managing care transitions Coordinating and sharing patient information with providers outside the practice CCM does not include any face-to-face service 29

CCM - Eligibility Providers participating in one of the following CMS models/demonstration programs cannot bill chronic care management (CCM) services for Medicare beneficiaries participating in the program; however, when appropriate, the practice can bill CCM services provided to Medicare beneficiaries who choose not to participate in the program. Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration Comprehensive Primary Care (CPC) Initiative 30

Who Can Bill CCM? When criteria is met the following providers can bill CCM Physicians Certified Nurse Midwives Clinical Nurse Specialists Nurse Practitioners Physician Assistants 31

Who Can Bill CCM Cont d Provider is responsible for managing the overall care plan. Beneficiary must have continuity of care with a designated practitioner or member of the care team with whom the beneficiary is able to get successive routine appointments. CANNOT bill TCM during the same calendar month. 32

Medicare Beneficiary Eligibility Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. 33

CCM Beneficiary Agreement A practitioner must inform eligible patients of the availability of and obtain consent for the CCM service before furnishing or billing the service. Informed patient consent need only be obtained once prior to furnishing the CCM service, or if the patient chooses to change the practitioner who will furnish and bill the service. 34

CCM Beneficiary Agreement Cont d This agreement process should include a discussion with the patient, and caregiver when applicable, about: What the CCM service is How to access the elements of the service How the patient s information will be shared among practitioners and providers How cost-sharing (co-insurance and deductibles) applies to these services How to revoke the service 35

Certified EHR Required In order to report and be paid for CCM services, the practice must be using a certified EHR meeting meaningful use criteria for the previous year. If the practice adopted a certified EHR and attested for the incentive payment in 2013, on December 31, 2014, Stage 1 meaningful use criteria are applicable. If the practice adopted and attested for the incentive payment in 2011, on December 31, 2014 Stage 2 meaningful use criteria are applicable. 36

CCM 1 st Step CMS requires the billing practitioner to furnish an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), or comprehensive evaluation and management visit to the patient prior to billing the CCM service, and to initiate the CCM service as part of this exam/visit. CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 37

Comprehensive Care Plan Create a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues). Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record. Ensure the care plan is available electronically at all times to anyone within the practice providing the CCM service. Share the care plan electronically outside the practice as appropriate 38

Comprehensive Care Plan Cont d A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements: Problem list Expected outcome and prognosis Measurable treatment goals Symptom management Planned interventions and identification of the individuals responsible for each intervention 39

Comprehensive Care Plan Cont d Medication management Community/social services ordered A description of how services of agencies and specialists outside the practice will be directed/coordinated Schedule for periodic review and, when applicable, revision of the care plan 40

24/7 Access The beneficiary must be provided with a means to make timely contact with health care providers in the practice whenever necessary to address chronic care needs regardless of the time of day or day of the week. Timely access includes enhanced opportunities for a patient to communicate with the provider regarding their care through not only the telephone but also through the use of asynchronous communication through secure email, text and other modalities to support access to health care. The patient s initial contact can be with clinical staff employed by the practice (for example, a nurse) and not necessarily with a provider. 41

Clinical Staff Clinical staff can be any individual who is acting under the supervision of a provider, regardless of whether the individual is an employee, leased employee, or independent contractor of the provider and meets any applicable requirements to provide the services, including licensure, imposed by the State in which the services are being furnished (42 CFR 410.26). 42

Clinical Staff Cont d CMS references CPT s definition of clinical staff. A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service, but does not individually report that professional service. CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 43

Medicare Clarifies Payment Policy for Anesthesia Services with Screening Colonoscopy CMS definition of colorectal cancer screening tests now includes anesthesia separately furnished in conjunction with screening colonoscopies. Effective for claims with dates of service on or after January 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy will report 00810 with G0105 and G0121. When billing 00810 in conjunction with the HCPCS codes for screening colonoscopy, anesthesia professionals must append modifier -33. CPT Codes, Descriptions, and Modifiers Copyright 2014 American Medical Association 44

Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations Advisory Committee on Immunization Practices (ACIP) now recommending administration of two different pneumococcal vaccinations. An initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare Part B. A different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered). 45

Pneumococcal Vaccinations Cont d New guidelines were effective September 19, 2014. Prior pneumococcal vaccination history should be taken into consideration. For example, if a beneficiary who is 65 years or older received the 23-valent pneumococcal polysaccharide vaccine (PPSV23) a year or more ago, then the 13- valent pneumococcal conjugate vaccine (PCV13) should be administered next as the second in the series of the two recommended pneumococcal vaccinations. 46

Intensive Behavioral Therapy for Obesity Medicare Coverage Update Intensive behavioral therapy for obesity became a covered preventive service under Medicare, effective November 29, 2011. G0447 (Face-to-face behavioral counseling for obesity, 15 minutes) ($24.98) Effective with dates of service on or after 1/1/2015, CMS covers behavioral group counseling for obesity. G0473 (Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes) ($12.07) 47

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