Wearables Will Soon Be Part of Major Shift In Medical Practice

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For a long time the idea of wearable health tracking devices seemed like an idea out of science fiction, but these days the technology is real and cost effective, and wearables will have a big effect on how your practice operates. Here with more insight on the nascent wearable industry is Guest Author Anne Zieger, CEO of Zieger Healthcare. – Abe

For most doctors in private practice, the astonishing growth of health wearables has all but passed them by.

Wearable Technology Will Soon be a Major Part of Medical PracticeAccording to a leading health IT group, the use of health and fitness apps is growing 87% faster than the entire mobile industry. That’s pretty astonishing for a product category most of us hadn’t even heard of five years ago.

But to date, this hasn’t changed medical practice much. While physicians may review readings gathered by consumer-grade measurement devices such as home glucose meters, blood pressure cuffs and pulse oximeters, few are integrating data from wearables into their consult, much less integrating that data into their EMR.

The reasons for this are many. For one thing, doctors are creatures of habit, and are unlikely to change their assessment routine unless they are pushed into doing so. What’s more, their EMRs are not set up to gather fitness data in a routine and streamlined data. Then when you consider that physicians aren’t quite sure what to do with the data – short of a shocking data outlier, what does a physician do with a few weeks of exercise data? – it seems even less likely that they’ll leverage wearables data into their clinical routine.

Over the next few years, however, this state of affairs should change dramatically.

Data analytics systems will begin to including wearables data into their calculations about individual and population health. And physicians will be expected to become adept at using wearables to better track the health status of chronically-ill patients. In short, wearables should fundamentally change the way physicians care for patients, especially those at greater risk.

Here’s some examples of how this will play out.

Data analytics

In an effort to improve the health of entire patient populations, organizations such Louisiana-based Ochsner Health System are testing Apple’s HealthKit technology. Through HealthKit, which connects with Ochsner’s Epic Systems EMR, the health system will be able to pull in and integrate a wide range of consumer-generated data, notably input from wearables.

While Ochsner’s first big win came from its test with wireless scales for heart patients—which led to a 40% decrease in admissions—the bigger picture calls for clinicians to use wearables data too, leveraging it to track the health of it entire patient base.

Tracking the chronically ill

Though most wearable health bands are consumer devices, used largely by the already fit to help them stay that way, medical device companies are building a new class of wearable devices designed to help clinicians track serious chronic illnesses in a serious manner.

Phillips, for example, announced a few months ago that it had released a biosensor patch designed to track symptoms of COPD, send the data to a cloud-based central software platform using the patient’s wireless device, then route the results to that patient’s clinician via a pair of related apps. This gives the physician 24-hour access to key indicators of COPD status, including respiratory rate, heart activity and rhythm and physical activity.

Conclusion: Much more to come

The bottom line in all of this is that wireless monitoring of remote patients has already arrived, and that new uses for data from health bands and other fitness devices are likely to become a standard part of patient care over the next few years.

While no one is suggesting that the data and practical observations a doctor gathers during a fact-to-face medical visit are becoming less value, medical practice is likely rely more heavily on monitoring of wearable smart bands, sensors, smart bands, sensor-laden smart clothing and more as time goes by. Now is a good time to prepare for this shift in medical practice, or risk getting left behind.

Anne Zieger of Zieger Healthcare

Anne Zieger is CEO of Zieger Healthcare

Zieger Healthcare’s team of veteran marketing communications pros will help you reach out to key healthcare stakeholders and grab their attention.  With decades of experience in the industry, we know exactly how to tell healthcare stories that sell.

 

Posted in: A Career in Practice Management, Electronic Medical Records, Innovation

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CMS and AMA Make ICD-10 “Family” Clarification

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Medicare will reimburse claims with ICD-10 codes as long as they are in the correct code "family" for 12 months.

Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities

Question 1:

When will the ICD-10 Ombudsman be in place?

Answer 1:

The Ombudsman will be in place by October 1, 2015.

Question 2:

Does the Guidance mean there is a delay in ICD-10 implementation?

Answer 2:

No. The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization. Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims.

Question 3:

What is a valid ICD-10 code?

Answer 3:

ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. To be valid, a code must be coded to the full number of characters required for that code, including the 7th character, if applicable. Many people use the term billable codes to mean valid codes. For example, E10 (Type 1 diabetes mellitus), is a category title that includes a number of specific ICD-10-CM codes for type 1 diabetes. Examples of valid codes within category E10 include E10.21 (Type 1 diabetes mellitus with diabetic nephropathy) which contains five characters and code E10.9 (Type 1 diabetes mellitus without complications) which contains four characters.

A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether additional characters are needed, such as the addition of a 7th character in order to arrive at a valid code.

Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?

Answer 4:

Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.

Question 5:

What is meant by a family of codes?

Answer 5:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Question 6:

Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

Answer 6:

In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.

Question 7:

National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?

Answer 7:

No. As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side. The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/.

Question 8:

Are technical component (TC) only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?

Answer 8:

Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.

Question 9:

Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?

Answer 9:

No, the audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.

MEDICAID

Question 10:

If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?

Answer 10:

State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner. Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met. If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare. Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.

Question 11:

Does this added ICD-10 flexibility regarding audits only apply to Medicare?

Answer 11:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. This Guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.

Question 12:

Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes?

Answer 12:

Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS and supported by valid, billable ICD-10 codes.

OTHER PAYERS

Question 13:

Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?

Answer 13:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. Each commercial payer will have to determine whether it will offer similar audit flexibilities.

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Posted in: Headlines, ICD-10, Medical Coding Education, Medicare & Reimbursement, Medicare This Week

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A Manage My Practice Classic: Five Simple but Powerful Performance Evaluation Questions

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Performance Review

This continues to be one of our top ranking posts of all time.

This tells me that people continue to struggle with the process of evaluating employee performance.

The point of the “Five Questions” evaluation is not to focus on the fact that the employee is often tardy or doesn’t complete assignments on time – those things should be initially dealt with outside of this process (remember the old adage “No new news at the performance evaluation.”) They can be added to #3 as goals, but the idea is to to dig under those things and see if the employee is dissatisfied, overwhelmed or under-challenged.

I typically use this form at 90 days after hire, then at the one year mark, then every 6 months thereafter.

Yes, evaluating this much is very time-consuming – but it pays BIG dividends.

Invest in your employees by using this form and meeting for at least an hour – you might be surprised that it’s one of the most in-depth evaluations you’ll ever do!

This is a VERY succinct performance evaluation that I’ve used for years. Called “Five Questions”, the employee completes it, submits it to the manager, then together they discuss, evaluate and add to it during the evaluation interview. Here are the questions:

  1. What goals did you accomplish since your last evaluation (or hire)?
  2. What goals were you unable to accomplish and what hindered you from achieving them?
  3. What goals will you set for the next period?
  4. What resources do you need from the organization to achieve these goals?
  5. Based on YOUR personal satisfaction with your job (workload, environment, pay, challenge, etc.) how would you rate your satisfaction from 1 (poor) to 10 (excellent.) 1 2 3 4 5 6 7 8 9 10

You do have to stress that question #5 is not how well they think they’re doing their job, but how satisfied they are with the job.

The great thing about this evaluation is that it is one piece of paper and not too intimidating. Staff can use phrases or sentences and write as little or as much as they like. If it’s hard to get a conversation going with the employee, ask them “What was your thought process when you assigned your job satisfaction a number __.” Usually that opens the floodgates!

If you use a goal-oriented evaluation like this one, you will find that employees will grasp that you are asking for their performance to be beyond the day-to-day tasks, and to focus on learning new skills, teaching others, creative thinking and problem-solving and new solutions for efficiency and productivity.

Posted in: Human Resources, Leadership, Manage My Practice Classics

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What Tools Will You Need for the ICD-10 Transition? Q & A with Swiftaudit

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Learn How to Crosswalk Your ICD-9s to ICD-10s

 

 

October 1, 2015 is a date that looms large for everyone involved in the operational and financial functions of any medical practice. At the time of this post’s publishing, practice administrators, managers, billers and coders have less than three months to make sure they have the processes and systems in place to minimize the business disruption from the changeover. As we talked to clients and readers about the challenges they are facing with the ICD-10 upgrade over the past several years, we started looking for tools that could help practices ease the transition.

One tool really stood out more than the others. Swiftaudit Search is a web-based coding conversion and look-up tool for both ICD-9 and ICD-10 code sets that we strongly endorse for its ability to supercharge ICD-10 coding, audits and upgrade preparations. We’ve been using Swiftaudit Search here at Manage My Practice for months now and we are very excited about how it can help our readers and clients.

We sat down with the creators of Swiftaudit Search, Chicago’s SpringSoft to ask them more about how practices can prepare for the upgrade.

Manage My Practice: Tell us about SpringSoft and how you starting working in the healthcare software market.

SpringSoft: We’ve provided software to the healthcare coding and compliance market since 1995. Our first product was E&M Coder™ for evaluation and management coding and audits. It all started when a few forward thinking doctors told us “the auditors are coming.” Given our background in corporate business systems, our research provided a couple of interesting observations at that time. One – physician offices had few easy to use software applications. Two – from a business point of view, physician offices needed help with coding and compliance. So we tackled a challenging little-understood coding issue in 1994 – the introduction of evaluation and management codes.

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Manage My Practice: Your product that is designed for medical coding has gone through several iterations since the ICD-10 mandate was first announced – how did your product evolve?

SpringSoft: We started designing what is now Swiftaudit Pro several years ago. As we designed the coding components, we realized that our ICD-10 Search features would benefit physicians during the transition to ICD-10. Again, we took on a daunting challenge. We knew we had to design an intuitive ICD-10 Search Feature. Once you find a group of codes, the next problem was to be present all of the ICD-10 coding information to describe the patient’s health condition. So now, as Swiftaudit evolves, our goal is to present the ICD-10 coding guidelines in a quick and straightforward way.

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Manage My Practice: We‘ve seen a wide variety of encoder-type products designed for hospitals and large organizations, and some designed for billing companies and consultants. What target market is the best fit for your products and why?

SpringSoft: Currently, we see our market as physician offices. Hospital and large organization coding systems have to address ‘packet’ coding, such as DRG (Diagnosis Related Groups) and HCCs (Hierarchical Condition Categories). Hospitals and large organizations will benefit from our auditing platform – SwiftAudit Pro. Providers who need to code ICD-10s will benefit from Swiftaudit Search. They can use our product to learn how code their common ICD-9 diagnosis in ICD-10 language.

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Manage My Practice: What do you hear are the biggest challenges faced by practices in making the transition to I-10?

SpringSoft: We hear that immediacy and time are the biggest challenges. Immediacy – it is always easier to learn new methods when you can consistently work in the new method. A baseline understanding helps provide context and what the changes are. We will all learn when everyone starts coding in ICD-10. Time – the change to ICD-10 is not trivial. It impacts the office’s income. Everyone will need to spend a little more time – coding in ICD-10, and time in improving their coding as payers respond to codes submitted. A practice can reduce frustration if they understand and prepare for their learning curve. Like all new methods, it takes practice to perfect.

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Manage My Practice: For many practices, their ability to utilize ICD-10 will come down to the support the EHR or Practice Management vendor has built into the software, yet many practices have not even seen how their software will work with ICD-10. What do recommend for practices whose software has not yet been updated to I-10, or whose software makes no useful correlation between I-9 and I-10?

SpringSoft: We agree with many consultants and trainers. Transition your top ICD-9 codes to specific ICD-10 codes. Be cautious of depending on published crosswalks. ICD-9s which describe ‘unspecified’ elements often are crosswalked to ‘unspecified’ ICD-10s. Experts in the industry are cautioning that ‘unspecified’ ICD-10s may not be paid. Ask your EMR vendor, will you handle all of the ICD-10 coding guidelines, such as Code First, Code Also, Use Additional Codes? Will you map to ‘unspecified’ ICD-10 codes or warn me of ‘unspecified’ ICD-10 codes? How will you help me find more specific codes? You can use Swiftaudit Search to build your Favorites Lists. We will provide you the ICD-10 coding guidelines, and provide a communication platform for your expert coders to provide you with coding tips and alerts.

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Manage My Practice: What are some of the features in Swiftaudit Search that your product has that others you’ve seen do not?

SpringSoft: We feel that our ease of use and screen design makes us stand out from the crowd. The ICD-10 code set is overwhelming. We’ve worked very hard to provide the information you need at a glance.

Swiftaudit Logo

 

Manage My Practice: Swiftaudit Pro (as opposed to Swiftaudit Search) is more for the coding and billing side of the practice. How do you see coders and billers using this product in their practices?

SpringSoft: Our background is in coding and compliance. Managers and auditors can use Swiftaudit Pro to improve their coding accuracy and educate their providers. We built Swiftaudit Pro to be a communication platform to aid discovery and process improvement between a practice’s providers and expert coders.

Readers who would like more information or would like to try Swiftaudit Search for free for 30-days can click here.

NOTE: We’ve heard of so many practices that have not started preparations for ICD-10 that that we made the 20-minute webinar “ICD-10 CM: Getting Started Today.” The video addresses strategies for the first step – crosswalking your most used ICD-9 codes into ICD-10.

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Posted in: Collections, Billing & Coding, Day-to-Day Operations, Electronic Medical Records, Headlines, ICD-10, Medicare & Reimbursement

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July 15-16 CMS Webinars: New Payment Model for Joint Replacements

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Surgeons Should Weigh In On Proposed CMS Joint Replacement Payment Model

UPDATED INFO: These recorded webinars are now available here.

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On July 9, 2015 the Centers for Medicare & Medicaid Services (CMS) announced the Comprehensive Care for Joint Replacement (CCJR) model, a proposed payment, quality, and care improvement initiative for hip and knee replacements.

The Center for Medicare & Medicaid Innovation (CMS Innovation Center) will host two offerings of a webinar to describe the proposed rule and respond to questions. The dates and registration links for these webinars are as follows:

Additional information on this Model can be accessed through the CCJR Model web page.

The proposed rule will undergo a 60-day comment period during which time CMS welcomes the input of stakeholders and the public. You can read the proposed rule in the Federal Register.

We encourage all interested parties to submit comments to the rule electronically through the CMS e-Regulation website at http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking or on paper by following the instructions included in the proposed rule. Submissions must be received by September 8, 2015.

*Large audiences are anticipated. Plan on joining a few minutes early.

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Posted in: Medicare & Reimbursement, Medicare This Week

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Before Starting a New Medical Practice Ask Yourself These 10 Questions

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Starting a New Medical Practice: Who's the Boss?

 

 

 

 

 

 

 

 

  1. Can I go without any income from a new practice for 3-6 months?
  2. Do I have another income stream or can I continue to work part-time at the hospital or at an urgent care while I’m building my practice?
  3. Can I envision starting my practice by myself (no receptionist or medical assistant)?
  4. Do I have an existing patient base which will be interested in joining my practice?
  5. Is the community in which I want to work underserved or overserved in my specialty?
  6. Do I have a cash component to my practice that can help defray expenses while I’m building my practice?
  7. Will I be able to count on unpaid help from my spouse, family or friends to get things started?
  8. Will I be satisfied to start my practice by leasing space from another practice, or at a less-prestigious location that might not be my forever-location?
  9. Am I willing to shop for gently used and refurbished furniture and equipment for my medical practice?
  10. Will I be satisfied to use one of the free EHRs, even if it doesn’t have all the bells and whistles?
  11. Bonus Question: Do I have saved or can I borrow $20K to cover my expenses for the first 3-6 months?

Starting a new medical practice is not easy. No one should tell you that it is.

But, if you want to put in the work, make the decisions, and ultimately, practice the way you want to, then a solo practice may be a fit for you.

You may have to call your friends and family together to help you, you may have to work someplace else while you’re building your practice, but the good news is, you are the boss of you.

Posted in: Innovation, Quality, Starting a New Practice

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The CMS ICD-10 Announcement: What It Means to Your Practice

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The Lion and the Lamb - CMS and the AMA Collaborate on ICD-10 Concessions

First, the game-changing announcement below means that a sigh of relief is in order. Some of the anxiety surrounding potential financial disaster should be abated. CMS announced:

“Medicare review contractors [MACs and RACs] will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.” (see FAQ2 below)

Second, we think it means that the sword rattling coming from the AMA and other individuals should subside. The fact that the CMS changes are based on recommendations from the AMA, which has been adamantly opposed to the ICD-10 mandate for years, is no less unexpected than the lion laying down with the lamb.

Regardless of the changes, the AMA’s previous assertion that ICD-10 “will create significant burdens on the practice of medicine with no direct benefit to individual patients’ care” still stands. The transition is inevitable, in my mind, but the changes will lessen the burden on physicians.

In the announcement from CMS, the clarification was made that

“In accordance with the coming transition, the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes.”

Third, CMS will name a CMS ICD-10 Ombudsman to triage and answer questions about the submission of claims. The ICD-10 Ombudsman will be located at CMS’s ICD-10 Coordination Center.

Also, mark your calendars! CMS will have a provider call on August 27th to discuss these changes.

See the answers below provided by CMS in their new FAQs published this week.

Q1. What if I run into a problem with the transition to ICD-10 on or after October 1st 2015?

A1. CMS understands that moving to ICD-10 is bringing significant changes to the provider community. CMS will set up a communication and collaboration center for monitoring the implementation of ICD-10. This center will quickly identify and initiate resolution of issues that arise as a result of the transition to ICD-10. As part of the center, CMS will have an ICD-10 Ombudsman to help receive and triage physician and provider issues. The Ombudsman will work closely with representatives in CMS’s regional offices to address physicians’ concerns. As we get closer to the October 1, 2015, compliance date, CMS will issue guidance about how to submit issues to the Ombudsman.

Q2. What happens if I use the wrong ICD-10 code, will my claim be denied?

A1. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting on October 1, 2015. It is possible a claim could be chosen for review for reasons other than the specificity of the ICD-10 code and the claim would continue to be reviewed for these reasons. This policy will be adopted by the Medicare Administrative Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

Q3. What happens if I use the wrong ICD-10 code for quality reporting? Will Medicare deny an informal review request?

A3. For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes. Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes. CMS will not deny any informal review request based on 2015 quality measures if it is found that the EP submitted the requisite number/type of measures and appropriate domains on the specified number/percentage of patients, and the EP’s only error(s) is/are related to the specificity of the ICD-10 diagnosis code (as long as the physician/EP used a code from the correct family of codes). CMS will continue to monitor the implementation and adjust the timeframe if needed.

Q4. What is advanced payment and how can I access this if needed?

A4. When the Part B Medicare Contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, an advance payment may be available. An advance payment is a conditional partial payment, which requires repayment, and may be issued when the conditions described in CMS regulations at 42 CFR Section 421.214 are met. To apply for an advance payment, the Medicare physician/supplier is required to submit the request to their appropriate Medicare Administrative Contractor (MAC). Should there be Medicare systems issues that interfere with claims processing, CMS and the MACs will post information on how to access advance payments. CMS does not have the authority to make advance payments in the case where a physician is unable to submit a valid claim for services rendered.

NOTE: Watch for upcoming posts on ICD-10 websites and apps that I am rating for their usefulness. We will also be producing free webinars on translating the diagnoses on your superbills, picklists and cheat sheets for ICD-10 – stay tuned!

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Posted in: Headlines, ICD-10

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How Much Does a Nurse Practitioner Get Paid?

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Nurse Practitioners (NPs) Are Sometimes Called Advance Practice Nurses (APNs)

I am often asked how much Nurse Practitioners in private medical practice should be paid.

This answer depends on a number of factors, not the least of which is the scope of practice for NPs in your state. Here are two handy links to laws for NPs in each state and what NPs in each state can and cannot do. 

In addition, NPs may make more or less depending on their duties, how much physician oversight they require, what the benefit package is, and if the NP will siphon off part of the existing providers’ practices, and therefore, income. Market rates are always important to review so an offer can be made that is somewhat comparable to other NP positions in the community, unless the work is less or more hours, less or more responsibility, etc.

Consider the following before making your offer:

Job Responsibilities

  • How many hours per week, on average, is the NP expected to work?
  • Will the NP take call?
  • Will the NP have his/her own patient panel?
  • Will the NP be expected to round on nursing home patients or hospital patients or admit or discharge patients (if allowed in your local hospitals)?
  • Will the NP staff a location without onsite physician support?
  • Will the NP be managing other staff or other mid-levels?

Support Required by the Physician

  • How much experience does the NP have overall, and how much in your specialty?
  • Will a physician be required to review some or all of the NP’s notes for sign-off for a defined period, or indefinitely?
  • Will the NP be able to write prescriptions for no drugs, some drugs or all drugs?
  • Will the NP see Medicare patients and thereby be limited to “incident-to” scheduling (the physician must see the patient initially and develop a care plan, then must see the patient every third visit for the initial problem, or every time a new problem is discussed.)

 Associated Costs with Hiring an NP

  • Wages: Base salary, any associated productivity bonuses
  • Benefits: paid time off, health insurance, life insurance, retirement matching (after one year), expense reimbursement (mileage, etc.)
  • Malpractice: many NPs and PAs may also want you to guarantee to pay for a malpractice “tail” when they leave your employment. They will need a tail only if your policy is claims made, which means they must pay for their own liability insurance after they leave you for acts when they worked with you. If you have an occurrence policy, it will pay if they were covered under the claim when the act happened, not when the suit was filed, so no tail is needed.
  • Licenses: Any software licenses for a new provider – some vendors equate NPs and PAs with a 1.0 FTE provider (full license fee) and other vendor equate them to a .5 FTE provider (1/2 license fee.)
  • Fees: Dues, licenses, subscriptions, DEA, memberships
  • Continuing Education: registration, travel, lodging, food, online CME, and do they get paid to take CME, or is CME paid for, but on their own time?
  • Electronics: Computer, laptop, tablet, iPad, smartphone, smartphone apps and add-ons
  • Medical Assistant: depending on your specialty the NP may need a FT medical assistant so they can be as productive as possible, or you may already have a medical assistant in-house that can be shared with the new NP. For some specialties, the NP may not need a medical assistant.
  • General Overhead: this is the biggest thing that practices overlook when they do not assign overhead costs to mid-level providers. All providers require a place to practice, staff assistants – clinical and/or administrative, equipment, medical consumables, etc. A percentage of the overhead should be considered an expense of employing the NP and should be accounted for before considering the NP to have made a profit for you during the year.
  • Marketing: how will you introduce the NP to the community and to your existing patients? Will you do a focused marketing campaign to encourage a target demographic to try the NP? Will you have an open house to introduce the NP to potential referrers in the community? Will you make contact with and provide flyers to assisted living facilities (Medicare) or daycares (pediatrics) or gyms (wellness, sports medicine, orthopedics) or other venues that match your target patient?
  • Miscellaneous Requests: signing bonus, office furniture, any special equipment based on personal characteristics or personal preferences (e.g. very short NPs may need a stool in each exam room or may request a hydraulic exam table), a computer at home for use when on call, relocation support, etc.
  • School Payback: There are programs available for school loan payback for mid-levels working in primary care and/or in underserved areas. This is a huge draw for many mid-level providers – take a minute and find out if these paybacks are available in your area. A new NP may be willing to take a little less in compensation if they are also eligible for loan forgiveness.

Things to Consider

  • What is the reason for adding an NP? To reduce other providers’ workload? To replace a retiring physician with a non-physician? To add a needed element to the practice (e.g. a female NP in an all-male practice or vice versa)? Improve the quality of life for existing providers (call, nursing home visits, discharges, etc.) Will an NP allow the group to bill for services previously billed outside the practice, such as first assist at surgery?
  • Will the NP make the market share pie bigger or take a piece of the existing market share pie? Has a projection been done to show the other physicians what their potential reduction in income will be if the NP takes part of the current market share? If the practice is going after new market share, how will this be achieved – general practice exposure vs niche marketing for a new service or something the NP brings to the table?
  • How much money will the practice have to expense before it sees a return on investment? How long will it take for the NP to cover his/her own expenses? How long will it take for the NP to cover expenses and bring additional income to the practice? Will additional formal or informal training be required? Will additional equipment for new services be required?
  • Reimbursement: What payers will pay the full allowable amount (billed under a physician) versus the allowable minus 15%?

Once you have considered everything above, take a look at the just-released 2015 National Nurse Practitioner Compensation Survey.

“Overall compensation for full-time nurse practitioners is on the rise, according to the American Association of Nurse Practitioners (AANP), which today released data from its 2015 National Nurse Practitioner Compensation Survey. The findings demonstrate that nurse practitioners who work 35 hours or more per week have seen average base salaries increase 6.3%, rising from $91,310 in 2011 to $97,083 in 2015, with total annual income increasing 10.0%, rising from $98,760 to $108,643. More than 2,200 nurse practitioners participated in the 2015 survey.”

The survey, which can be purchased for $50, shows the breakout of compensation based on education, experience, region, setting and specialty.

NOTE: If your practice needs helps running the numbers to see how adding an NP or PA will affect expenses and revenue, Manage My Practice has a Pro Forma Service which helps you to make a job offer knowing what your costs will be, how many patients need to be seen to cover costs and how soon after the hire the practice can potentially see a return on their investment. Contact us here or call Mary Pat at (919) 370.0504.

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EMV: How Your Practice Will Be Affected By Credit Card Changes in October 2015

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EMV Chip on a VISA CardAt Manage My Practice, we are big proponents of using a Credit Card on File (CCOF) system in medical practices to reduce expenses and improve cash flow. Knowing how your processing vendor’s pricing plan and security features work are critical to implementing this system. You have to be able to understand and negotiate your costs, and stay current on best practices and technology that keep your patients’ data safe.

Big changes are coming to the technology end of your credit card system in October of this year (as if you won’t be busy enough with ICD-10!) and you need to make sure now that you have all the details handled for your employees and your patients. The new technology is called EMV, or “Euro Mastercard Visa” and has been used in most of the rest of the world for awhile now.

Whenever we have questions about anything credit card related, we go straight to Michael Gutlove, Director of Merchant Services at IDT. Michael has been our own vendor, as well as our top recommendation to clients for almost three years now. We asked him to help us sort out the changes.


 

Mary Pat: Michael, what’s your background?

Michael: I’ve been helping business owners improve their bottom lines since 1997. Reducing costs are critical – now more than ever – for all business owners, and I’ve been able to repeatedly reduce operating costs by clearing away the traditional smoke and mirrors of credit card processing.

Mary Pat: Are people in general and patients specifically using credit cards more than they used to? Do you foresee a time when people will only use credit cards, no cash or checks?

Michael: While electronic payment volume has steadily increased year after year it’s highly unlikely that cash or checks will ever be completely eliminated. Cash payments serve the “underbanked” population and checks remain a highly effective method of payment for high ticket (luxury) items.

Mary Pat: What about payment via a smartphone or watch – do you see that becoming a predominant part of the American payment experience?

Michael: Apple Pay is the first mobile wallet solution that’s made any traction into the payment space. It’s opened the door for cell phone manufacturers, wireless carriers, and any/every technology company under the moon to think about getting involved. The problem with suggesting that mobile technology will replace the way we pay (or become the primary way we pay) is that it’s not fixing an existing problem. Mobile payments are generally viewed as a convenience as opposed to a necessity and we’ve become accustomed to carrying a wallet or purse with actual credit cards.

October 1 Change to EMV Terminals

Mary Pat: The new acronym in credit cards is EMV. What is EMV?

Michael: EMV stands for Europay MasterCard Visa. It’s an acronym for the Global standard of chip card technology facilitating electronic payment transactions. The United States is the last major country to adopt this method.

Mary Pat: Why do readers need to know about EMV?

Michael: October 2015 marks the deadline for business owners, accepting credit or debit cards, to upgrade their terminals for chip card acceptance. While it is not legally necessary to upgrade, doing so reduces the liability for fraudulent or counterfeit duplicate transactions.

Mary Pat: What does accepting chip cards have to do with liability?

Michael: EMV prevents “card present” duplicate fraud as the customer always maintains possession of their card. Instead of swiping the mag-stripe on the back, merchants will instruct customers to insert cards into the EMV ready terminal and enter a PIN or signature when prompted. Businesses that do not have the ability to accept EMV cards will be held liable for fraudulent “swiped” transactions.

Mary Pat: Does EMV eliminate fraud?

Michael: EMV is not a cure all for all types of fraud. The programs put in place will help with duplicate card fraud charge-backs, but will not impact others. Visa, MasterCard, Discover, and American Express have different liability shift requirements.

Mary Pat: What about “Card Not Present” transactions?

Michael: EMV only applies to face-to-face transactions. When it was released in Europe increased levels of fraud showed up via ecommerce and MOTO (mail order/telephone order). A similar scenario is expected once the US adopts EMV making PCI-DSS compliance even more important.

Mary Pat: What is PCI?

Michael: PCI–DSS stands for the Payment Card Industry Data Security Standard. Most processors offer comprehensive programs to ensure PCI compliance and validation.

Mary Pat: What should I do now?

Michael: Reach out to your processor and determine your risk level for EMV. Accepting EMV can only help your business but it isn’t necessary to do anything prior to October. The majority of POS (point of sale) manufacturers haven’t released EMV readers and new hardware might not be necessary depending on your existing terminal make & model.


Making sure you are getting the most you can from your credit card vendor is a critical part of protecting your data and your bottom line in today’s healthcare industry. You need to know the steps you and your vendors are taking to safeguard patient data as well as being able to relay those steps back to patients and employees. That’s why it’s important for managers to understand EMV – and their credit card setup in general. Successful implementation of a credit card on file program or any credit card processing system will always require buy-in and communication.

NOTE: Credit Card on File clients of Manage My Practice should know that Michael Gutlove will be swapping out your current swipers for EMV terminals for chip and non-chip cards at a considerable discount.

For additional information, questions, or anything else credit card related feel free to reach out to Michael Gutlove at 201.281.1621.

Posted in: Collections, Billing & Coding, Compliance, Day-to-Day Operations, Finance, Headlines

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Chronic Care Management Q&A: Will Your Patients Agree to Pay?

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Non-Face-to-Face Chronic Care Management Services Q&A

Can Physicians Get Paid for Chronic Care Management?

Everyone was very excited when Medicare announced its policy to start paying in 2015  for Chronic Care Management (CCM) services – non face-to-face services that physicians have been providing to their patients for free for a very long time.

CPT 99490 is the CCM code that is defined by the AMA as:

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.

Physicians, Certified Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners and Physician Assistants may provide CCM services, however only one provider of any kind may submit a claim and be reimbursed for the service during any given month.

The code is reimbursed by the month and the national average reimbursement by Medicare is $42.91.

But the fly in the ointment has quickly surfaced – patients are not necessarily willing to agree to the services. A provider must inform eligible patients of the availability of and obtain consent for the CCM service before furnishing or billing the service.

Why wouldn’t a patient agree to the service?

Because they are responsible for the standard 20% cost-sharing (approximately $8.40) of the service after they have met their annual deductible of $147.00. Patients may decline to pay for something they’ve been getting for free, or something they feel they are already paying for through the cost of office visits.

Here are the Q&As Medicare Released Last Week

1. CPT code 99490 requires at least 20 minutes of time per calendar month by “clinical staff” in order to bill the code. Who qualifies as “clinical staff”? If the billing physician (or other appropriate practitioner) furnishes services directly, does their time count towards the required minimum 20 minutes of time?

In most cases, we believe clinical staff will provide CCM services incident to the services of the billing physician (or other appropriate practitioner who can be a physician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife). Practitioners should consult the CPT definition of the term “clinical staff.” In addition, time spent by clinical staff may only be counted if Medicare’s “incident to” rules are met such as supervision, applicable State law, licensure and scope of practice. If the billing physician (or other appropriate billing practitioner) provides CCM services directly, that time counts towards the 20 minute minimum time. Of course, other staff may help facilitate CCM services, but only time spent by clinical staff may be counted towards the 20 minute minimum time.

2. Can CCM services be subcontracted out to a case management company? What if the clinical staff employed by the case management company are located outside of the United States?

A billing physician (or other appropriate practitioner) may arrange to have CCM services provided by clinical staff external to the practice (for example, in a case management company) if all of the “incident to” and other rules for billing CCM to the PFS are met. Because there is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9), CCM services cannot be billed if they are provided to patients or by individuals located outside of the United States.

3. Does the billing practice have to furnish every scope of service element in a given service period, even those that may not apply to an individual patient?

It is our expectation that all of the scope of service elements will be routinely provided in a given service period, unless a particular service is not medically indicated or necessary (for example, the beneficiary has no hospital admissions that month so there is no management of a transition after hospital discharge).

4. What date of service should be used on the physician claim and when should the claim be submitted?

The service period for CPT 99490 is one calendar month, and CMS expects the billing practitioner to continue furnishing services during a given month as applicable after the 20 minute time threshold to bill the service is met (see #3 above). However practitioners may bill the PFS at the conclusion of the service period or after completion of at least 20 minutes of qualifying services for the service period. When the 20 minute threshold to bill is met, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month.

5. What place of service (POS) should be reported on the physician claim?

Practitioners must report the POS for the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient). Accordingly, practitioners who furnish CCM in the hospital outpatient setting, including provider-based locations, must report the appropriate place of service for the hospital outpatient setting). Payment for CCM furnished and billed by a practitioner in a facility setting will trigger PFS payment at the facility rate.

6. CPT code 99490 is payable to hospital outpatient departments (provider-based locations) under the hospital Outpatient Prospective Payment System (OPPS). Can physicians practicing in these departments or in locations that are hospital-owned (but not provider-based) also bill this code to the PFS? What if the patient is a hospital or SNF inpatient or is otherwise in a Medicare “facility” or “institution?”

If the patient resides in a community setting and the CCM service is provided by or “incident to” services of the billing physician (or other appropriate billing practitioner) working in or employed by a hospital, CPT 99490 can be billed to the PFS and payment is made at the facility rate (if all other billing requirements are met). We discuss this further under the section below addressing billing for CCM furnished in the hospital outpatient department setting.

As we discussed in the CY 2014 PFS final rule, the resources required to provide care management services to patients in facility settings significantly overlap with care management activities by facility staff that are included in the associated facility payment. Therefore, CPT 99490 cannot be billed to the PFS for patients who reside in a facility (that receives payment from Medicare for care of that beneficiary, see 78 FR 74423) regardless of the location of the billing practitioner, because the payment made to the facility under other payment systems includes care management and coordination. For example, CPT code 99490 cannot be billed to the PFS for services provided to SNF inpatients or hospital inpatients, because the facility is being paid for extensive care planning and care coordination services. However if the patient is not an inpatient the entire month, time that is spent furnishing CCM services to the patient while they are not inpatient can be counted towards the minimum 20 minutes of service time that is required to bill for that month.

Billing practitioners in hospital-owned outpatient practices that are not provider-based departments are working in a non-facility setting, and may therefore bill CPT 99490 and be paid under the PFS at the non-facility rate. However, CPT 99490 can only be billed for CCM services furnished to a patient who is not a hospital or SNF inpatient and does not reside in a facility that receives payment from Medicare for that beneficiary.

7. Is a new patient consent form required each calendar month or annually?

No, as provided in the CY 2014 PFS final rule (78 FR 74424), a new consent is only required if the patient changes billing practitioners, in which case a new consent must be obtained and documented by the new billing practitioner prior to furnishing the service.

8. Is Medicare now paying separately under the PFS for remote patient monitoring services described by CPT code 99091 or similar CPT codes?

CPT 99091 continues to be bundled with other services for payment under the PFS. As per CPT guidance, CPT codes 99090, 99091 and other codes cannot be billed during the same service period as CPT 99490. However as discussed in the CY 2015 PFS final rule (79 FR 67727), analysis of patient-generated health data and other activities described by CPT 99091 or similar codes may be within the scope of CCM services, in which case these activities would count towards the minimum 20 minutes of qualifying care per month that are required to bill CPT 99490. But in order to bill CPT 99490, such activity cannot be the only work that is done—all other requirements for billing CPT 99490 must be met in order to bill the code, and time counted towards billing CPT 99490 cannot also be counted towards billing other codes.

9. If a physician arranges to furnish CCM services to his/her patients “incident to” using a case management entity outside the billing practice, does the billing physician need to ever see the patient face-to-face?

Yes, as provided in the CY 2014 final rule (78 FR 74425), CCM must be initiated by the billing practitioner during a comprehensive Evaluation & Management (E/M) visit, annual wellness visit (AWV) or initial preventive physical exam (IPPE). This face-to-face visit is not part of the CCM service and can be separately billed to the PFS, but is required before CCM services can be provided directly or under other arrangements. The billing practitioner must discuss CCM with the patient at this visit. While informed patient consent does not have to be obtained during this visit, it is an opportunity to obtain the required consent. The face-to-face visit included in transitional care management (TCM) services (CPT 99495 and 99496) qualifies as a comprehensive visit for CCM initiation. CPT codes that do not involve a face-to-face visit by the billing practitioner or are not payable by Medicare (such as CPT 99211, anticoagulant management, online services, telephone and other E/M services) do not meet the requirement for the visit that must occur before CCM services are furnished. If the practitioner furnishes a comprehensive E/M, AWV, or IPPE and does not discuss CCM with the patient at that visit, that visit cannot count as the initiating visit for CCM.

10. Do face-to-face activities count as billable time?

CPT 99490 describes activities that are not typically or ordinarily furnished face-to-face, such as telephone communication, review of medical records and test results, and consultation and exchange of health information with other providers. If these activities are occasionally provided by clinical staff face-to-face with the patient but would ordinarily be furnished non-face-to-face, the time may be counted towards the 20 minute minimum to bill CPT 99490. However, see #11 below regarding care coordination services furnished on the same day as an E/M visit.

11. Medicare and CPT allow billing of E/M visits during the same service period as CPT 99490. If an E/M visit or other E/M service is furnished the same day as CCM services, how do I allocate the total time between CPT 99490 and the other E/M code(s)?

Under longstanding Medicare guidance, only one E/M service can be billed per day unless the conditions are met for use of modifier -25. Time cannot be counted twice, whether it is face-to-face or non-face-to-face time, and Medicare and CPT specify certain codes that cannot be billed for the same service period as CPT 99490 (see #12, 13 below). Face-to-face time that would otherwise be considered part of the E/M service that was furnished cannot be counted towards CPT 99490. Time spent by clinical staff providing non-face-to-face services within the scope of the CCM service can be counted towards CPT 99490. If both an E/M and the CCM code are billed on the same day, modifier -25 must be reported on the CCM claim.

12. Medicare and CPT specify that CCM and TCM cannot be billed during the same month. Does this mean that if the 30-day TCM service period ends during a given calendar month and 20 minutes of qualifying CCM services are subsequently provided on the remaining days of that calendar month, CPT code 99490 cannot be billed that month to the PFS?

CPT 99490 could be billed to the PFS during the same calendar month as TCM, if the TCM service period ends before the end of a given calendar month and at least 20 minutes of qualifying CCM services are subsequently provided during that month. However we expect that the majority of the time, CCM and TCM will not be billed during the same calendar month.

13. Are there any other services that cannot be billed under the PFS during the same calendar month as CPT 99490?

Yes, Medicare does not allow CPT 99490 to be billed during the same service period as home health care supervision (HCPCS G0181), hospice care supervision (HCPCS G0182) or certain ESRD services (CPT 90951-90970) because care management is an integral part of all of these services. Also see CPT coding guidance for a list of additional codes that cannot be billed during the same month as CPT 99490. There may be additional restrictions on billing for practitioners participating in a CMS model or demonstration program; if you participate in one of these separate initiatives, please consult the CMS staff responsible for these initiatives with any questions on potentially duplicative billing.

14. Can I bill CPT 99490 if the beneficiary dies during the service period?

CPT 99490 can be billed if the beneficiary dies during the service period, as long as at least 20 minutes of qualifying services were furnished during that calendar month and all other billing requirements are met.

15. Will practitioners be able to use an acceptably certified electronic health record (EHR) technology for which certification expires mid-year in order to bill for CCM? For example, can they use technology certified to the 2011 Edition to fulfill the scope of services required to bill CPT 99490 in 2015 once this technology no longer bears a “2011 Edition certified” mark?

Yes. Under the CCM scope of services, practitioners must use technology certified to the Edition(s) of certification criteria that is acceptable for the EHR Incentive Programs as of December 31st of the year preceding each CCM payment year. In certain years, this may mean that practitioners can fulfill the scope of services requirement using multiple Editions of certification criteria. For instance, for payment in 2015, practitioners may use technology certified to either the 2011 or 2014 Edition of certification criteria to meet the EHR scope of service requirements, as both Editions could be used to meet the requirements of the EHR Incentive Programs as of December 31, 2014. This remains true for a given PFS payment year even after ONC-Authorized Certification Bodies (ONC-ACBs) have removed the certifications issued to technology certified to a given acceptable edition (e.g., the 2011 Edition for CCM payment in 2015) as a result of the relevant criteria being removed from the Code of Federal Regulations. Thus, practitioners using an acceptable EHR technology that loses its certification mid-year may still use that technology to fulfill the certified EHR criteria for billing CPT 99490 during the applicable payment year.

16. Does the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10) affect the billing rules for CCM services?

No, Section 103 of the MACRA codifies payment broadly for chronic care management services under the PFS, authorizing PFS payment after January 1, 2015, for CCM services furnished by physicians and the non-physician practitioners that Medicare generally recognizes to furnish and bill for E/M services (physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives). It does not impact the current billing and payment rules for CPT 99490. It provides that provision of an AWV or IPPE in advance shall not be a condition of payment for CCM services, which is consistent with our current policy. It also provides that payment shall not be duplicative of other Medicare payments, consistent with the rules we have implemented to date regarding duplicative payment for CPT 99490.

17. Where can I find more guidance on CCM billing requirements?

A Fact Sheet on CCM is available on the CMS website here. The scope of service elements and other requirements for billing CCM to the PFS are also laid out in the CY 2014 and CY 2015 PFS final rules (CMS-1600-FC, CMS-1612-FC and CMS-1612-F2, available on the CMS website here. Most of the requirements were finalized in the CY 2014 PFS final rule, effective CY 2015. The CY 2015 final rule with comment period and correction notice address supervision and other “incident to” rules, electronic health record and other electronic technology requirements, valuation, and intersection with CMS’ care coordination models and demonstrations. Regarding the intersection with CMS’ care coordination models and demonstrations, please consult the CMS staff responsible for those projects. You may also direct questions to your Medicare Administrative Contractor.

18. Are hospital outpatient departments (HOPDs) eligible to bill CPT code 99490 under the OPPS?

Yes, CPT code 99490 is payable under the OPPS when certain requirements are met (see details in question #19 on billing requirements). As CPT code 99490 is defined as a physician-directed service, the OPPS provides payment to the HOPD when the hospital’s clinical staff furnishes the service at the direction of the physician (or other appropriate practitioner). Payment under the OPPS represents only payment for the facility portion of the service. Payment for the physician’s (or other appropriate practitioner’s) time directing CCM services in the HOPD setting is made under the PFS at the facility rate.

19. What are the requirements to bill CCM under the OPPS?

CPT code 99490 is a physician-directed service that is only payable under the OPPS when the hospital’s clinical staff furnishes the service at the direction of the physician (or other appropriate practitioner). The billing physician or practitioner directing the CCM services must meet the requirements to bill CCM services under the PFS, when the CCM service is furnished in the physician office or the hospital outpatient department. Specifically, a hospital outpatient department may bill and be paid for CCM services furnished to eligible hospital outpatients under the OPPS if the hospital’s clinical staff furnishes at least 20 minutes of care management services under the direction of the physician (or other appropriate practitioner) during the calendar month and the billing physician or practitioner directing the CCM services satisfies the billing requirements for CPT code 99490 under the PFS including the following requirements:

  • Patient Eligibility—Patient has 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.
  • Patient Agreement— Patient consent to receive CCM services has been obtained by the practitioner and documented in the medical record.
  • CCM Scope of Service Elements including Structured Data Reporting, Care Plan, Access to Care, and Care Management of the patient are furnished by the hospital.
  • Hospital furnished the CCM services using a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31st of the calendar year preceding each Medicare PFS payment year (referred to as “CCM certified technology”). The hospital must also meet the requirements to use electronic technology in providing CCM services, such as 24/7 access to the care plan, and electronic sharing of the care plan and clinical summaries (other than by fax), specified in the CY 2014 and CY 2015 PFS final rules.

20. How does CMS define a “hospital outpatient” for whom a hospital may bill CCM services (CPT code 99490)?

Per section 20.2 of publication 100-04 of the Medicare Claims Processing Manual, a hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital. Since CPT code 99490 will ordinarily be performed non face-to-face (see # 10 above), the patient will typically not be a registered outpatient when receiving the service. In order to bill for the service, the hospital’s clinical staff must provide at least 20 minutes of CCM services under the direction of the billing physician or practitioner. Because the beneficiary has a direct relationship with the billing physician or practitioner directing the CCM service, we would expect a beneficiary to be informed that the hospital would be performing care management services under their physician or other practitioner’s direction.

21.When CCM services are furnished by a physician in a hospital outpatient department, can the physician and the hospital both bill Medicare for the CCM service?

Yes, when certain conditions are met. Specifically, when CCM services are furnished by a physician in a hospital outpatient department to an eligible patient, the physician may bill Medicare for CPT code 99490 under the PFS reporting place of service (POS) 22 (outpatient hospital), which will indicate that PFS payment should be made at the facility rate, and the hospital may bill for CPT code 99490 under the OPPS.

22. Can more than one hospital bill and be paid for furnishing CCM services if the patient has been a registered hospital outpatient at more than one hospital over a 12 month span? If only one hospital can bill and receive payment for CCM services, which hospital is allowed to bill?

CPT code 99490 is only payable under the OPPS when the hospital’s clinical staff furnishes the CCM service at the direction of a qualified physician (or other appropriate practitioner). As only one physician or practitioner is allowed to bill under the PFS for CPT 99490 during a calendar month service period, accordingly, only one hospital is allowed to bill and be paid for CPT code 99490 for a particular beneficiary during a calendar month service period. We would expect the hospital billing for CPT code 99490 under physician direction to have access to the patient’s consent to receive CCM services documented in the patient’s medical record. The patient may choose a different practitioner to furnish CCM at the conclusion of the service period, at which time the practitioner assuming the provision of CCM services will be required to have the patient consent of CCM services documented in the patient’s medical record. New patient consent is only required if the patient chooses a new practitioner to furnish CCM services, in which case a new consent must be documented in the patient’s medical record prior to furnishing the service.

23. Is CPT code 99490 payable to provider-based hospital outpatient departments under the hospital Outpatient Prospective Payment System (OPPS)? May a hospital-owned practice that is not provider-based bill the OPPS for CCM services?

A provider-based outpatient department of a hospital is part of the hospital and therefore may bill for CCM services furnished to eligible patients, provided that it meets all applicable requirements. A hospital-owned practice that is not provider-based to a hospital is not part of the hospital and, therefore, not eligible to bill for services under the OPPS; but the physician (or other qualifying practitioner) practicing in the hospital-owned practice may bill under the PFS for CCM services furnished to eligible patients, provided all PFS billing requirements are met.

24. What is the supervision level for CCM services furnished in the hospital setting?

CPT code 99490 is assigned a general supervision level under the OPPS when furnished in the hospital setting. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually perform the procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Are your patients signing up for CCM services? Tell us in the comments!

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