Rick Bikowski MD Chief Quality Officer, EVMS Medical Group CARE MANAGEMENT

Rick Bikowski MD Chief Quality Officer, EVMS Medical Group CARE MANAGEMENT

Medicare Wellness Visit: Background Until recently, Medicare did not pay for preventive services Welcome to Medicare visit initiated January 1, 2005 aka Initial Preventive Physical Examination (IPPE) One time benefit within the first 12 months of enrolling into Medicare The Patient Protection and Affordable Care Act of 2010 added a new annual benefit for preventative care Annual Wellness Visit (MWV or AWV) Benefit started January 1, 2011

IPPE/MVW: What Are They? These are not physical exams Directed more towards preventive care in the elderly Components are to promote good medicine Although given different names, the exams are similar Differ by when you can do them

Elements of the Initial Annual Wellness Visit Past Medical & Surgical History & Hospitalizations Family History Medications including Supplements/OTC Current Medical Providers Height, Body Weight, BMI or waist circumference, BP Cognitive Screen Depression Screen Functional Assessment Minimum: Hearing, ADL s, fall risk and home safety screens Written Personalized Health Plan based on USPSTF and Advisory Committee on Immunization Practices Individualized based on health status Prevention Appropriate referrals to health education or preventative counseling services Including weight loss, physical activity, smoking cessation, fall prevention and nutrition Voluntary Advance Care Planning Verbal or written Review Chronic Illness Health Risk Assessment Care Plan

Elements of Subsequent AWV Update of Medical & Family History Update Current Providers Weight or waist circumference, BP Detection of any cognitive impairment Written Personalized Health Plan Updated Appropriate referrals to health education or preventative counseling services Voluntary Advance Care Planning Written or verbal

No deductible or co-pay for patient

G0402 $165.20 G0438 $171.51 G0439 $115.33 No deductible or co-pay for patient

Why TOC? Good patient care, good continuity at vulnerable exchange points that contribute to cost, utilization, and decreased quality and safety Increased cost and penalties result from avoidable readmissions (18% 30 day readmission rate, ~ half preventable, $44 Billion / year) TOC models reduce readmissions

Evidence Only high-intensity interventions seemed to be effective in reducing short-term readmissions high-intensity interventions that include care coordination by a nurse, communication between the primary care provider and the hospital, and a home visit within three days after discharge HEALTH AFFAIRS 33, NO. 9 (2014): 1531 1539, 2014 Transitional care resources would be best allocated toward ensuring that highest risk patients receive follow-up within 7 days. Ann Fam Med March/April 2015 vol. 13 no. 2 115-122

Why TOC? CMS and some commercial payers reward TOC efforts (support care management capabilities): Medicare, Optima, United, some Cigna 99495 (14 day follow up, mod complex): ~ $163-220 99496 (7 day follow up, high complex): ~ $229-310

Why TOC? Helps With (MIPS 2017/2019) 50 % 10% 15% 25% 0-100 Points Reduce Cost: TOC is a Performance TOC, Using Summary Reduce 30 Day All Medical Spending Per Improvement Activity of Care is a key Cause Readmissions Beneficiary, Episode in the Care performance measure (1/7 quality measures) Costs Coordination Category in Meaningful Use

Transitions of Care: Key Components Discharge from hospital, rehab, or skilled nursing home discharge (how do you know) Patient non face to face contact 2 business days with documentation Face to face follow up 7 or 14 days, document complexity of medical decision making Can now submit on the day of the encounter Only one care management code per 30 day period (cannot bill again if 30 readmission) https://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf

Transitional Care Management Performed by licensed clinical staff or case manager under direction of qualified professional: communicate with home health agencies and other community services utilized by patient educate patient and/or family/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 facilitate access to necessary care and services Performed by a qualified professional: obtain and review discharge information follow-up on, pending diagnostic tests and treatments interact with other providers involved in patient s care educate patient, family, guardian, and/or caregiver arrange for needed community resources

Transitions of Care: Discussion How do you know a patient was discharged? Hospital, Nursing Home Who contacts patient by 2 business days? What do they document? Who schedules the follow up appointment? Do you have dedicated schedule time? How long the visit? Who submits the code? Do providers know how to document high complexity medical decision making? How do you track 30 day readmissions? Do you track TOC success (percent of discharges seen, billed)?

How Do We Know About Discharge? Hospitalists notification ADT message Summary of Care C CDA direct message Custom EPIC report Connect Virginia HIE Alert

99495 or 99496? http://www.aafp.org/dam/aafp /documents/practice_manage ment/payment/tcm30day.pdf

Track TOC Progress Transition of Care - June 2016 Medicare and Optima patients seen in the last 18 mths and have a Hosp DC CPT, FM Discharge FU Phone Call Note, a Hosp DC TOC Note, and/or a TOC CPT submitted. Division # HOSP DC Last 15-60 Days #FM Discharge FU Phone Call < 4 Days from DC Date %FM Discharge FU Phone Call < 4 Days from DC Date #Hosp DC TOC Note < 15 Days from DC Date %Hosp DC TOC Note < 15 Days from DC Date # TOC Charge Submitted < 60 Days %TOC Charge Submitte d < 60 Days # HOSP DC Last 12 Mths # TOC Charge Submitte d 12 Mths % Compliant < 12 Mths GHENT FAMILY MEDICINE 22 15 68.18 % 13 59.09 % 10 45.45 % 148 81 54.73 % PORTSMOUTH FAMILY MEDICINE 14 3 21.43 % 3 21.43 % 1 7.14 % 79 55 69.62 % PRIMARY CARE INTERNAL MEDICINE 23 8 34.78 % 10 43.48 % 4 17.39 % 170 52 30.59 % Totals 59 26 44.07 % 26 44.07 % 15 25.42 % 397 188 47.36 %

SQCN: Referrals and Transitions of Care 19

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CHRONIC CARE MANAGEMENT

CCM Codes: What You Need To Do Initiation: Annual Wellness Visit (AWV), Welcome to Medicare/initial preventive physician examination (IPPE), or face-to-face E/M visit, for new patients or patients not seen within 1 year prior to the commencement of chronic care management (CCM) services. Inform the beneficiary; that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time. Document in the beneficiary s medical record that the required information was explained and whether the beneficiary accepted or declined the services. Creation, revision and/or monitoring of an electronic patient-centered comprehensive care plan for all health issues Electronically capture care plan information. Share care plan information electronically (can include fax) within and outside the billing practice to individuals involved in the beneficiary s care. A copy of the plan of care must be given to the patient and/or caregiver.

CPT 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

CPT 99487 Complex chronic care management services, 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; Establishment or substantial revision of a comprehensive care plan; Moderate or high complexity medical decision-making; 0 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month CPT 99489 Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

G0506 is meant to account specifically for additional work of the billing provider in: Personally performing CCM care planning Note that this Chronic Care Management care planning could be faceto-face and/or non-face-to-face, but the time spent doing the CCM care planning must not already be reflected in the CCM initiating visit itself or in the time spent during the monthly CCM (i.e., in CPT 99490, CPT 99487, CPT 99489) The G0506 code is particularly appropriate when the CCM initiating visit is a less complex visit (such as a level 2 or 3 E/M visit). G0506 can be billed along with higher level E&M visits if the practitioner s effort and time exceeded the usual effort described in the initial visit E&M code. G0506 can also be billed when the initiating E&M visit addresses problems unrelated to Chronic Care Management and the CCM related work is not included in the initial visit code. G0506 is meant to be billed only once per beneficiary during the initiation of the patient into Chronic Care Management.

Chronic Care Management: Medicare CODE DESCRIPTION FEE 99490 Chronic care management services $47 99487 Complex CCM services $93.67 99489 Each additional 30 minutes $44 G0505 Cognition and functional assessment $227 G0506 Comprehensive assessment and care plan $63.88