Suzanne Niemi, CPA, CMPE, CCE Alaska Primary Care Association April 2017 Medicare Part A & Part B MACRA / MIPS Chronic Care Management Billing WHY SHOULD A CHC/FQHC CARE?
2 DEFINITIONS FQHC Federally Qualified Health Center Safety Net Provider that offers services typically furnished in an outpatient setting: Community Health Centers CHC Look-Alikes Outpatient programs operated by a tribe, tribal organization or Urban Indian organization Organizations must apply for this status
3 DEFINITIONS FQHC Medicare Reimbursement Reimbursement under Medicare Part A through the Prospective Payment System (PPS) Paid at a per-encounter rate vs. being paid on the Fee-for- Service model based on procedure codes FQHC-eligible providers must apply to Medicare Part A
4 DEFINITIONS MACRA = Medicare Access and CHIP Reauthorization Act of 2015 Pay-for-performance program that s focused on quality, value, and accountability MACRA replaced three Medicare reporting programs with MIPS Medicare Meaningful Use (MU) Physician Quality Reporting System (PQRS) Value-Based Payment Modifier MIPS = Merit-Based Incentive Payment System A performance-based payment system for Medicare Part B clinicians which requires submission of performance data to CMS
5 DEFINITIONS CCM = Chronic Care Management Billing Reimbursement from Medicare for certain services provided to patients with multiple (two or more) chronic conditions
MACRA and MIPS 6
7 DOES MACRA /MIPS APPLY TO CHCS? Federally Qualified Health Centers (FQHCs) are exempt from MIPS reporting Aren t all CHCs considered FQHCs? NO!! FQHC is a term related to billing / reimbursement methodology CHCs must apply to Medicare Part A to be recognized and reimbursed as an FQHC
MEDICARE PART A vs. MEDICARE PART B 8
PATIENT ENROLLMENT / COVERAGE FOR SERVICES IN A CHC 9 CHC Sends FQHC Claims to Medicare Part A Patient must be enrolled in Medicare Part B CHC Sends Fee-for-Service Claims to Medicare Part B Patient must be enrolled in Medicare Part B Patient enrollment in Part A covers Hospital, Skilled Nursing, Nursing Home, Hospice and Home Health services Patient enrollment in Part B covers Outpatient services, Ambulance, Durable Medical Equipment, Mental Health Patients must be enrolled in Part B for Medicare to cover services provided by an outpatient clinic, regardless of how the provider submits claims
PROVIDER ENROLLMENT 10 Medicare Part A Enroll as an organization using Form CMS-855A Requires organization level information Includes names and information of governing board members and Executive Director (managing employee) Medicare Part B Enroll the group using CMS-Form 855B Enroll individual providers using CMS Form 855I
BENEFITS OF ENROLLMENT 11 Medicare Part A Medicare FQHC per-encounter reimbursement rates For non-tribal organizations: Determines eligibility to receive state Medicaid FQHC perencounter reimbursement rates Do not need to individually enroll providers in Medicare Part A Medicare Part B Ability to bill Medicare for services to beneficiaries Ability to bill for services not reimbursable under Part A (see additional slide for details on what services cannot be billed to Part A)
12 WHY NOT ENROLL? Medicare Part A Some tribal providers have decided that the reimbursement benefit does not outweigh the reporting burden Medicare Part B No services are provided to Medicare beneficiaries No services are provided that are outside of the Medicare Part A scope
SPECIAL REPORTING REQUIREMENTS 13 Medicare Part A Must submit a quarterly Credit Balance Report to CMS on Form CMS-838 Must submit a Medicare Cost report annually 5 months after year end. (much simpler than a hospital cost report) Alaska Medicaid requires non-tribal entities to submit a copy of the Medicare Cost Report to Medicaid Medicare Part B None Periodic re-validation required
14 WHAT SERVICES CAN BE BILLED? Medicare Part A Services provided to Medicare beneficiaries furnished by a Physician Nurse practitioner (NP) Physician assistant (PA) Certified nurse midwife (CNM) Clinical psychologist (CP) Clinical social worker (CSW), or Certified diabetes self-management training/medical nutrition therapy (DSMT/MNT) provider Medicare Part B Most services provided to Medicare beneficiaries See next page for exclusions Part A providers can bill certain services to Part B (those that cannot be reimbursed under Part A)
15 WHAT SERVICES ARE EXCLUDED? Medicare Part A exclusions Services that can be billed to Part B: Services provided by practitioners other than those in the previous slide Laboratory services Technical components of diagnostic services Durable Medical Equipment / Prosthetic devices / body braces https://med.noridianmedicare.com/web/jea/ provider-types/fqhc/fqhc-billing-guide Medicare Part B exclusions Some of the items and services that Medicare doesn't cover at all include: Long-term care (also called custodial care) Most dental care Eye examinations related to prescribing glasses Dentures Cosmetic surgery Acupuncture Hearing aids and exams for fitting them Routine foot care
16 HOW ARE CLAIMS FILED? Medicare Part A Submitted to Part A using UB-04 Medicare Part B Submitted to Part B using CMS-1500 Health Centers are required to use special CPT codes when submitting Medicare claims in addition to regular CPT codes. G0466, G0467, G0468, G0469 and G0470
17 HOW IS THE REIMBURSEMENT AMOUNT DETERMINED? Medicare Part A Prior to 2014, the Medicare FQHC per-encounter was cost-based, but was subject to a cap of about $112 Beginning with fiscal years starting Oct 1, 2014 Health Centers are paid on a Prospective Payment System (PPS) The rates for 2017: $163.49 National Base Rate 1.318 AK geographic adjustment factor (GAF) $215.48 ESTABLISHED PATIENT VISIT 1.3416 High Intensity Visit Adjustment $289.09 NEW PATIENT, INITIAL PREV PHYSICAL EXAM (IPPE) OR ANNUAL WELLNESS VISIT (AWV) Medicare Part B Per the Physician Fee Schedule updated annually by CMS The same payment rates as a private practice provider
18 HOW DOES ENROLLMENT AFFECT THE PATIENT? Medicare Part A There is no Part B deductible for FQHC-covered services Coinsurance is 20 percent of the lesser of the FQHC s charge for the specific payment code or the PPS rate, except for certain preventive services Patient cost-sharing requirements for most Medicare covered preventive services are waived, and Medicare pays 100 percent of the costs for these services No coinsurance is required for the IPPE, AWV, and any covered preventive services recommended with a grade of A or B by the United States Preventive Services Task Force. Medicare Part B Usual Deductibles and 20% Co-Payments Same as if they saw a private provider More information on Medicare Part A / FQHC co-insurance For a complete list of preventive services and their coinsurance requirements, refer to the Federally Qualified Health Center (FQHC) Preventive Services Chart. https://www.cms.gov/medicare/medicare-fee-for-service- Payment/FQHCPPS/Downloads/FQHC-Preventive- Services.pdf
19 ARE CHRONIC CARE MGMT SERVICES PAID? Medicare Part A Yes Code 99490 Only Cannot bill for new complex CCM codes Payment is based on the Medicare PFS national non-facility payment rate. The rate is updated annually and has no geographic adjustment Medicare Part B Yes Can bill all CCM codes
20 DOES MACRA / MIPS APPLY? Medicare Part A FQHC Medicare Part A providers are exempt from mandatory MIPS reporting Organizations may choose to report Medicare Part B MIPS reporting periods begin in 2017 There are penalties for not reporting Payment adjustments (+ or ) are scheduled to be implemented in 2019 based on 2017 data
21 ARE ALL ALASKA CHCS ENROLLED IN PART A? Non-Tribal CHCs Yes. All Alaska Non-Tribal CHCs have applied for Part A recognition Non-Tribal CHCs must receive designation as a Medicare FQHC in order to qualify for state Medicaid FQHC reimbursement Tribal CHCs Maybe Tribal Organizations enroll in Medicaid as a tribal entity Medicare FQHC enrollment is not required as a condition of enhanced Medicaid reimbursement Each Organization makes an individual decision whether or not to enroll in Part A
22 MACRA and MIPS Medicare Access and CHIP Reauthorization Act of 2015 Merit-Based Incentive Payment System
23 MIPS REPORTING REQUIREMENT The Quality Payment Program improves Medicare by helping you focus on care quality and the one thing that matters most making patients healthier. Federally Qualified Health Centers (FQHCs) are exempt from MIPS reporting But, providers may choose to report There are over 270 measures to choose from 55 specifically for General Practice / Family Medicine https://qpp.cms.gov/measures/quality
24 MEDICARE PART A PAYMENT CHANGES BASED ON MIPS REPORTING NO CHANGE TO FQHC PER-ENCOUNTER PAYMENT RATES For FQHCs, it is important to note that MACRA/QPP implementation will not impact your Medicare FQHC PPS payments Because health centers are paid their unique Medicare PPS and are not paid on the Physician Fee Schedule ( Part B ) they will not be subject to MIPS and their payment methodology will not change. Health Centers will be able to voluntarily report under the new MIPS, without incentive or penalty.
25 WHAT ABOUT FQHCs THAT SUBMIT SOME CLAIMS TO PART B? While Part A payments will not be affected, reimbursement for any Part B claims may be affected Services that are billed outside of the FQHC benefit and billed to Medicare Part B separately are subject to MIPS. Check the low volume thresholds (see slide #27)
MEDICARE PART B PAYMENT CHANGES BASED ON MIPS REPORTING 26
27 MIPS ELIGIBILITY Providers are eligible to participate in the MIPS track of the Quality Payment Program if: You bill more than $30,000 to Medicare, and You provide care to more than 100 Medicare patients per year, and You are a: Physician Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist
28 MIPS REPORTING PARTICIPATE AS AN INDIVIDUAL OR A GROUP? Individual One NPI tied to one Tax ID Group A group is defined as a set of clinicians (identified by their NPIs) sharing a common Tax Identification Number, no matter the specialty or practice site. To submit data through the CMS web interface, you must register as a group by June 30, 2017.
29 MIPS REPORTING TIMELINE If you re ready, you can begin January 1, 2017 and start collecting your performance data If you re not ready on January 1, you can choose to start anytime between January 1 and October 2, 2017 Whenever you choose to start, you ll need to send in your performance data by March 31, 2018 The first payment adjustments based on performance go into effect on January 1, 2019
30 MIPS REPORTING CATEGORY #1 Quality (replaces PQRS) Most participants: Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days Groups using the web interface: Report 15 quality measures for a full year
31 MIPS REPORTING - CATEGORY #2 Improvement Activities Participants in certified patient-centered medical homes, comparable specialty practices, or an APM designated as a Medical Home Model: You will automatically earn full credit Most participants: Attest that you completed up to 4 improvement activities for a minimum of 90 days Groups with fewer than 15 participants or if you are in a rural or health professional shortage area: Attest that you completed up to 2 activities for a minimum of 90 days
32 MIPS REPORTING CATEGORY #3 Advancing Care Information (replaces Meaningful Use) Fulfill the required measures for a minimum of 90 days: Security Risk Analysis e-prescribing Provide Patient Access Send Summary of Care Request/Accept Summary of Care Choose to submit up to 9 measures for a minimum of 90 days for additional credit
MIPS REPORTING CATEGORY #4 33 Cost No data submission required Calculated from adjudicated claims
34 HOW TO SUBMIT DATA Individual Providers Send individual data for each of the MIPS categories through an electronic health record or a registry. You can also send in quality data through your routine Medicare claims process. https://qpp.cms.gov/learn/getprepared Groups (registration open from April 1 June 30, 2017) Options may vary based on performance category CMS Web Interface (only available to groups with 25 or more eligible clinicians) Qualified Clinical Data Registry (QCDR) Qualified Registry Electronic Health Record (EHR) Administrative Claims CAHPS for MIPS Survey (only available to groups with 2 or more eligible clinicians) Attestation https://qpp.cms.gov/learn/about-groupregistration
35 MIPS RESOURCES https://qpp.cms.gov/ https://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/value-based-programs/macra-mips-and-apms/macra-mipsand-apms.html
CHRONIC CARE MANAGEMENT (CCM) 36
37 CHRONIC CARE MANAGEMENT Definition: Services by a physician or non-physician practitioner (PA, NP, Clinical Nurse Specialist, Certified Nurse-Midwife, and their clinical staff, At least 20 minutes per calendar month, for 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. Comprehensive care plan established, implemented, revised, or monitored Note that only 1 practitioner can bill CCM per service period (month)
38 EXAMPLES OF CHRONIC CONDITIONS INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING: Alzheimer s disease and related dementia Arthritis (osteoarthritis and rheumatoid) Asthma Atrial fibrillation Autism spectrum disorders Cancer Cardiovascular Disease Chronic Obstructive Pulmonary Disease Depression Diabetes Hyperlipidemia Hypertension Infectious diseases such as HIV/AIDS Ischemic Heart Disease Kidney Disease (Chronic) Osteoporosis Stroke
39 CHRONIC CARE MANAGEMENT SERVICES The CCM service is extensive, including Structured recording of patient health information in a certified EHR Maintaining a comprehensive electronic Care Plan Access to Care & Care Continuity Comprehensive Care Management Transitional Care Management Coordinating and sharing patient health information timely within and outside the practice.
40 COMPREHENSIVE CARE PLAN 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 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
41 Initiating Visit: 2017 FQHC BILLING REQUIREMENTS For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner: An Annual Wellness Visit (AWV), or Initial Preventive Physical Exam (IPPE), or Other face-to-face visit with the billing practitioner This initiating visit is not part of the CCM service and is separately billed
42 2017 FQHC BILLING REQUIREMENTS The FQHC must inform eligible patients of the availability of CCM services and obtain consent for the CCM service before furnishing or billing the service. Patient consent requirements include: Informing the patient of the availability of the CCM service Obtaining written agreement to have the services provided, including authorization for the electronic communication of medical information with other treating practitioners and providers Explaining and offering the CCM service to the patient and documenting this discussion in the patient s medical record, noting the patient s decision to accept or decline the service. Informing the patient of the right to stop CCM services at any time (effective at the end of the calendar month) Informing the patient that only one practitioner can furnish and be paid for the service during a calendar month
43 CCM BILLING In November 2016, CMS announced rule changes Enables reimbursement for more complex and more time-intensive chronic care coordination effective January 2017. HOWEVER, these new codes are not available to FQHCs Only CPT 99490 is payable in FQHC and RHC settings. Complex CCM is not payable and there is no add-on code/separate payment for initiating visits
44 THIS IS THE ONLY CODE THAT CAN BE BILLED BY Federally Qualified Health Centers (FQHCs) CCM BILLING CODE FOR FQHCs CPT code 99490 Allows eligible practitioners and suppliers to bill for at least 20 minutes of non-face-to-face clinical staff time directed by a physician or other qualified health professionals each month to coordinate care for beneficiaries who have two or more serious chronic conditions that are expected to last at least 12 months.
CCM ADDITIONAL BILLING CODES (not available to FQHCs) HCPCS code G0506 An add-on code to the CCM initiating visit for providing a comprehensive assessment and care planning to patients. CPT code 99487 Complex CCM that requires substantial revision of a care plan, moderate or high complexity medical decision making, and 60 minutes of clinical staff time. CPT code 99489 complex CCM add-on code for each additional 30 minutes of clinical staff time. 45
2017 REIMBURSEMENT RATES 46
47 2017 FQHC BILLING DETAILS CCM services can be billed alone or on the same claim as an office visit Must be billed on or before the last day of the month Must include at least 2 chronic condition diagnosis codes Billed each month that services have been documented. Does not need to be consecutive months No revenue code restrictions Note that time spent must be documented
48 2017 CCM BILLING SUMMARY FQHCs can bill for CCM services when a FQHC practitioner furnishes a comprehensive evaluation and management (E/M) visit, Annual Wellness Visit (AWV), or Initial Preventive Physical Examination (IPPE) to the patient prior to billing the CCM service, and initiates the CCM service as part of this visit. CCM payment will be based on the Medicare Physician Fee Schedule national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services on a FQHC claim. The rate will be updated annually and has no geographic adjustment. The FQHC face-to-face requirements are waived when CCM services are furnished to a FQHC patient.
49 2017 CCM BILLING SUMMARY (cont d) Coinsurance would be applied as applicable to FQHC claims. FQHCs would continue to be required to meet the FQHC Conditions of Participation and any additional FQHC payment requirements. FQHCs cannot bill for CCM services for a beneficiary during the same service period as billing for transitional care management or any other program that provides additional payment for care management services (outside of the FQHC PPS payment) for the same beneficiary.
50 CCM BENEFITS TO THE PATIENT The patient will experience many benefits from participating in the program: 24 7 access to care coordination Monthly consultations via non face to face communication such as telephone Care Plan progress reviews The potential to identify escalating conditions before an emergency event occurs Improved quality of health by consistent monitoring
51 CCM BENEFITS TO THE HEALTH CENTER Health Centers will also benefit from participating in the program: Activities are in line with Patient Centered Medical Home and UDS Measure Quality Improvement initiatives. Health Centers will receive payment for activities that are already taking place Provides level of accountability for follow-up on chronic care patients Will prepare the Health Center for billing CCM services to Commercial Payers as available.
52 CCM RESOURCES CCM Fact Sheet All Providers ***** Good source of information**** https://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf CMS Care Management Webpage https://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/Care-Management.html CCM Services Changes for 2017-Medicare Learning Network https://www.cms.gov/outreach-and-education/medicare-learning- Network- MLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2 017.pdf
53 CCM RESOURCES MLN Matters CCM Services for FQHCs and RHCs - MM9234 Revised https://www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNMattersArticles/Downloads/MM9234.pdf CCM FAQs for FQHCs as of February 19, 2016 https://www.cms.gov/medicare/medicare-fee-for-service- Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf CCM FAQs as of January 18, 2017 All Providers https://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ. pdf
54 APCA RESOURCES APCA Training & Technical Assistance Staff Patty Linduska pattyl@alaskapca.org Penney Benson penneyb@alaskapca.org Lesley de Jaray lesleyd@alaskapca.org Marie Jackman mariej@alaskapca.org Suzanne Niemi suzannen@alaskapca.org Tara Ferguson taraf@alaskapca.org Tom Taylor tomt@alaskapca.org Bree Villar breev@alaskapca.org 907-929-2722