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New Rules for Charging Patients for Their Medical Records

Charges for Medical Records Change

 

Just when you thought you understood how to charge for medical records!

New clarifications have just been released that give specific direction to medical practices and other healthcare providers on charging patients for medical records. I have extracted the most salient pieces for you below, followed by FAQs from the published clarifications.

  1. Covered entities must inform the individual in advance of the approximate/exact fee that may be charged for the copy.
  2. A covered entity can develop a schedule of costs for labor based on average labor costs to fulfill standard types of access requests (e.g. paper records, electronic records, mailed records, etc.)
  3. A covered entity may charge individuals a flat fee for all standard requests for electronic copies of PHI maintained electronically, provided the fee does not exceed $6.50, inclusive of all labor, supplies, and any applicable postage. While the Privacy Rule permits the limited fee as described, covered entities should provide individuals who request access to their information with copies of their PHI free of charge.
  4. The fee limits apply when an individual directs a covered entity to send the PHI to a third party (and it doesn’t matter who the third party is) HOWEVER, where the third party is initiating a request for PHI on its own behalf, with the individual’s HIPAA authorization (or pursuant to another permissible disclosure provision in the Privacy Rule), the access fee limitations do not apply.
  5. Administrative and other costs associated with outsourcing the function of responding to individual requests for access cannot be the basis for any fees charged to individuals for providing that access.
  6. A covered health care provider cannot charge an individual a fee when it fulfills an individual’s HIPAA access request using the View, Download, and Transmit functionality of the provider’s CEHRT.
  7. HIPAA does not override those State laws that provide individuals with greater rights of access to their health information than the HIPAA Privacy Rule does
  8. A covered entity may not charge an individual who, while inspecting her PHI, takes notes, uses a smart phone or other device to take pictures of the PHI, or uses other personal resources to capture the information, however, a covered entity is not required to allow the individual to connect a personal device to the covered entity’s systems.
  9. A covered entity may not withhold or deny an individual access to his PHI on the grounds that the individual has not paid the bill for health care services.

May a covered entity charge individuals a fee for providing the individuals with a copy of their PHI?

Yes, but only within specific limits. The Privacy Rule permits a covered entity to impose a reasonable, cost-based fee to provide the individual (or the individual’s personal representative) with a copy of the individual’s PHI, or to direct the copy to a designated third party. The fee may include only the cost of certain labor, supplies, and postage:

  1. Labor for copying the PHI requested by the individual, whether in paper or electronic form.  Labor for copying includes only labor for creating and delivering the electronic or paper copy in the form and format requested or agreed upon by the individual, once the PHI that is responsive to the request has been identified, retrieved or collected, compiled and/or collated, and is ready to be copied.  Labor for copying does not include costs associated with reviewing the request for access; or searching for and retrieving the PHI, which includes locating and reviewing the PHI in the medical or other record, and segregating or otherwise preparing the PHI that is responsive to the request for copying.While it has always been prohibited to pass on to an individual labor costs related to search and retrieval, our experience in administering and enforcing the HIPAA Privacy Rule has shown there is confusion about what constitutes a prohibited search and retrieval cost and this guidance further clarifies this issue.  This clarification is important to ensure that the fees charged reflect only what the Department considers “copying” for purposes of applying 45 CFR 164.524(c)(4)(i) and do not impede individuals’ ability to receive a copy of their records.
  2. Supplies for creating the paper copy (e.g.,  paper, toner) or electronic media (e.g., CD or USB drive)if the  individual requests that the electronic copy be provided on portable media.  However, a covered entity may not require an  individual to purchase portable media; individuals have the right to have their  PHI e-mailed or mailed to them upon request.
  3. Labor to prepare an explanation or summary of the PHI, if the individual in advance both chooses to receive an explanation or summary and agrees to the fee that may be charged.
  4. Postage, when the individual requests that the copy, or the summary or explanation, be mailed.

Thus, costs associated with updates to or maintenance of systems and data, capital for data storage and maintenance, labor associated with ensuring compliance with HIPAA (and other applicable law) in fulfilling the access request (e.g., verification, ensuring only information about the correct individual is included, etc.) and other costs not included above, even if authorized by State law, are not permitted for purposes of calculating the fees that can be charged to individuals.  See 45 CFR 164.524(c)(4).

Further, while the Privacy Rule permits the limited fee described above, covered entities should provide individuals who request access to their information with copies of their PHI free of charge.  While covered entities should forgo fees for all individuals, not charging fees for access is particularly vital in cases where the financial situation of an individual requesting access would make it difficult or impossible for the individual to afford the fee.  Providing individuals with access to their health information is a necessary component of delivering and paying for health care. We will continue to monitor whether the fees that are being charged to individuals are creating barriers to this access, will take enforcement action where necessary, and will reassess as necessary the provisions in the Privacy Rule that permit these fees to be charged.

What labor costs may a covered entity include in the fee that may be charged to individuals to provide them with a copy of their PHI?

A covered entity may include reasonable labor costs associated only with the: (1) labor for copying the PHI requested by the individual, whether in paper or electronic form; and (2) labor to prepare an explanation or summary of the PHI, if the individual in advance both chooses to receive an explanation or summary and agrees to the fee that may be charged.

Labor for copying includes only labor for creating and delivering the electronic or paper copy in the form and format requested or agreed upon by the individual, once the PHI that is responsive to the request has been identified, retrieved or collected, compiled and/or collated, and is ready to be copied.  For example, labor for copying may include labor associated with the following, as necessary to copy and deliver the PHI in the form and format and manner requested or agreed to by the individual:

  • Photocopying paper PHI.
  • Scanning paper PHI into an electronic format.
  • Converting electronic information in one format to the format requested by or agreed to by the individual.
  • Transferring (e.g.,  uploading, downloading, attaching, burning) electronic PHI from a covered entity’s system to a web-based portal (where the PHI is not already maintained in or accessible through the portal), portable media, e-mail, app, personal health record, or other manner of delivery of the PHI.
  • Creating and executing a mailing or e-mail with the responsive PHI.

While we allow labor costs for these limited activities, we note that as technology evolves and processes for converting and transferring files and formats become more automated, we expect labor costs to disappear or at least diminish in many cases.

In contrast, labor for copying does not include labor costs associated with:

  • Reviewing the request for access.
  • Searching for, retrieving, and otherwise preparing the responsive information for copying.  This includes labor to locate the appropriate designated record sets about the individual, to review the records to identify the PHI that is responsive to the request and to ensure the information relates to the correct individual, and to segregate, collect, compile, and otherwise prepare the responsive information for copying.

May a covered health care provider charge a fee under HIPAA for individuals to access the PHI that is available through the provider’s EHR technology that has been certified as being capable of making the PHI accessible?

No.  The HIPAA Privacy Rule at 45 CFR 164.524(c)(4) permits a covered entity to charge a reasonable, cost-based fee that covers only certain limited labor, supply, and postage costs that may apply in providing an individual with a copy of PHI in the form and format requested or agreed to by the individual.  Where an individual requests or agrees to access her PHI available through the View, Download, and Transmit functionality of the CEHRT, we believe there are no labor costs and no costs for supplies to enable such access.  Thus, a covered health care provider cannot charge an individual a fee when it fulfills an individual’s HIPAA access request using the View, Download, and Transmit functionality of the provider’s CEHRT.

May a covered entity that uses a business associate to act on individual requests for access pass on the costs of outsourcing this function to individuals when they request copies of their PHI?

No.  A covered entity may charge individuals a reasonable, cost-based fee that includes only labor for copying the PHI, costs for supplies, labor for creating a summary or explanation of the PHI if the individual requests a summary or explanation, and postage, if the PHI is to be mailed.  See 45 CFR 164.524(c)(4).  Administrative and other costs associated with outsourcing the function of responding to individual requests for access cannot be the basis for any fees charged to individuals for providing that access.

Must a covered entity inform individuals in advance of any fees that may be charged when the individuals request a copy of their PHI?

Yes.  When an individual requests access to her PHI and the covered entity intends to charge the individual the limited fee permitted by the HIPAA Privacy Rule for providing the individual with a copy of her PHI, the covered entity must inform the individual in advance of the approximate fee that may be charged for the copy.  An individual has a right to receive a copy of her PHI in the form and format and manner requested, if readily producible in that way, or as otherwise agreed to by the individual.  Since the fee a covered entity is permitted to charge will vary based on the form and format and manner of access requested or agreed to by the individual, covered entities must, at the time such details are being negotiated or arranged, inform the individual of any associated fees that may impact the form and format and manner in which the individual requests or agrees to receive a copy of her PHI.  The failure to provide advance notice is an unreasonable measure that may serve as a barrier to the right of access. Thus, this requirement is necessary for the right of access to operate consistent with the HIPAA Privacy Rule.  Further, covered entities should post on their web sites or otherwise make available to individuals an approximate fee schedule for regular types of access requests.  In addition, if an individual requests, covered entities should provide the individual with a breakdown of the charges for labor, supplies, and postage, if applicable, that make up the total fee charged.  We note that this information would likely be requested in any action taken by OCR in enforcing the individual right of access, so entities will benefit from having this information readily available.

How can covered entities calculate the limited fee that can be charged to individuals to provide them with a copy of their PHI?

The HIPAA Privacy Rule permits a covered entity to charge a reasonable, cost-based fee for individuals (or their personal representatives) to receive (or direct to a third party) a copy of the individuals’ PHI.  In addition to being reasonable, the fee may include only certain labor, supply, and postage costs that may apply in providing the individual with the copy in the form and format and manner requested or agreed to by the individual.  A covered entity may calculate this fee in three ways.

  • Actual costs.  A covered entity may calculate actual labor costs to fulfill the request, as long as the labor included is only for copying (and/or creating a summary or explanation if the individual chooses to receive a summary or explanation) and the labor rates used are reasonable for such activity.  The covered entity may add to the actual labor costs any applicable supply (e.g., paper, or CD or USB drive) or postage costs.  Covered entities that charge individuals actual costs based on each individual access request still must be prepared to inform individuals in advance of the approximate fee that may be charged for providing the individual with a copy of her PHI.  An example of an actual labor cost calculation would be to time how long it takes for the workforce member of the covered entity (or business associate) to make and send the copy in the form and format and manner requested or agreed to by the individual and multiply the time by the reasonable hourly rate of the person copying and sending the PHI.  What is reasonable for purposes of an hourly rate will vary depending on the level of skill needed to create and transmit the copy in the manner requested or agreed to by the individual (e.g., administrative level labor to make and mail a paper copy versus more technical skill needed to convert and transmit the PHI in a particular electronic format).
  • Average costs. In lieu of calculating labor costs individually for each request, a covered entity can develop a schedule of costs for labor based on average labor costs to fulfill standard types of access requests, as long as the types of labor costs included are the ones which the Privacy Rule permits to be included in a fee (e.g., labor costs for copying but not for search and retrieval) and are reasonable.  Covered entities may add to that amount any applicable supply (e.g., paper, or CD or USB drive) or postage costs.
    • This standard rate can be calculated and charged as a per page fee only in cases where the PHI requested is maintained in paper form and the individual requests a paper copy of the PHI or asks that the paper PHI be scanned into an electronic format.  Per page fees are not permitted for paper or electronic copies of PHI maintained electronically.  OCR is aware that per page fees in many cases have become a proxy for fees charged for all types of access requests – whether electronic or paper – and that many states with authorized fee structures have not updated their laws to account for efficiencies that exist when generating copies of information maintained electronically.  This practice has resulted in fees being charged to individuals for copies of their PHI that do not appropriately reflect the permitted labor costs associated with generating copies from information maintained in electronic form.  Therefore, OCR does not consider per page fees for copies of PHI maintained electronically to be reasonable for purposes of 45 CFR 164.524(c)(4).
  • Flat fee for electronic copies of PHI maintained electronically.  A covered entity may charge individuals a flat fee for all standard requests for electronic copies of PHI maintained electronically, provided the fee does not exceed $6.50, inclusive of all labor, supplies, and any applicable postage.

Are costs authorized by State fee schedules permitted to be charged to individuals when providing them with a copy of their PHI under the HIPAA Privacy Rule?

No, except in cases where the State authorized costs are the same types of costs permitted under 45 CFR 164.524(c)(4) of the HIPAA Privacy Rule, and are reasonable.  The bottom line is that the costs authorized by the State must be those that are permitted by the HIPAA Privacy Rule and must be reasonable.  The HIPAA Privacy Rule at 45 CFR 164.524(c)(4) permits a covered entity to charge a reasonable, cost-based fee that covers only certain limited labor, supply, and postage costs that may apply in providing an individual with a copy of PHI in the form and format requested or agreed to by the individual.  Thus, labor (e.g., for search and retrieval) or other costs not permitted by the Privacy Rule may not be charged to individuals even if authorized by State law.  Further, a covered entity’s fee for providing an individual with a copy of her PHI must be reasonable in addition to cost-based, and there may be circumstances where a State authorized fee is not reasonable, even if the State authorized fee covers only permitted labor, supply, and postage costs.  For example, a State-authorized fee may be higher than the covered entity’s cost to provide the copy of PHI.  In addition, many States with authorized fee structures have not updated their laws to account for efficiencies that exist when generating copies of information maintained electronically.  Therefore, these State authorized fees for copies of PHI maintained electronically may not be reasonable for purposes of 45 CFR 164.524(c)(4).

A State law requires that a health care provider give individuals one free copy of their medical records but HIPAA permits the provider to charge a fee.  Does HIPAA override the State law?

No, so the health care provider must comply with the State law and provide the one free copy.  In contrast to State laws that authorize higher or different fees than are permitted under HIPAA, HIPAA does not override those State laws that provide individuals with greater rights of access to their health information than the HIPAA Privacy Rule does.  See 45 CFR 160.202 and 160.203.  This includes State laws that: (1) prohibit fees to be charged to provide individuals with copies of their PHI; or (2) allow only lesser fees than what the Privacy Rule would allow to be charged for copies.

When do the HIPAA Privacy Rule limitations on fees that can be charged for individuals to access copies of their PHI apply to disclosures of the individual’s PHI to a third party?

The fee limits apply when an individual directs a covered entity to send the PHI to the third party.  Under the HIPAA Privacy Rule, a covered entity is prohibited from charging an individual who has requested a copy of her PHI more than a reasonable, cost-based fee for the copy that covers only certain labor, supply, and postage costs that may apply in fulfilling the request.  See 45 CFR 164.524(c)(4).  This limitation applies regardless of whether the individual has requested that the copy of PHI be sent to herself, or has directed that the covered entity send the copy directly to a third party designated by the individual (and it doesn’t matter who the third party is).  To direct a copy to a third party, the individual’s access request must be in writing, signed by the individual, and clearly identify the designated person or entity and where to send the PHI.  See 45 CFR 164.524(c)(3)(ii).  Thus, written access requests by individuals to have a copy of their PHI sent to a third party that include these minimal elements are subject to the same fee limitations in the Privacy Rule that apply to requests by individuals to have a copy of their PHI sent to themselves.  This is true regardless of whether the access request was submitted to the covered entity by the individual directly or forwarded to the covered entity by a third party on behalf and at the direction of the individual (such as by an app being used by the individual).  Further, these same limitations apply when the individual’s personal representative, rather than the individual herself, has made the request to send a copy of the individual’s PHI to a third party.

In contrast, third parties often will directly request PHI from a covered entity and submit a written HIPAA authorization from the individual (or rely on another permission in the Privacy Rule) for that disclosure.  Where the third party is initiating a request for PHI on its own behalf, with the individual’s HIPAA authorization (or pursuant to another permissible disclosure provision in the Privacy Rule), the access fee limitations do not apply.  However, as described above, where the third party is forwarding – on behalf and at the direction of the individual – the individual’s access request for a covered entity to direct a copy of the individual’s PHI to the third party, the fee limitations apply.

We note that a covered entity (or a business associate) may not circumvent the access fee limitations by treating individual requests for access like other HIPAA disclosures – such as by having an individual fill out a HIPAA authorization when the individual requests access to her PHI (including to direct a copy of the PHI to a third party).  As explained elsewhere in the guidance, a HIPAA authorization is not required for individuals to request access to their PHI, including to direct a copy to a third party – and because a HIPAA authorization requests more information than is necessary or that may not be relevant for individuals to exercise their access rights, requiring execution of a HIPAA authorization may create impermissible obstacles to the exercise of this right.  Where it is unclear to a covered entity, based on the form of a request sent by a third party, whether the request is an access request initiated by the individual or merely a HIPAA authorization by the individual to disclose PHI to the third party, the entity may clarify with the individual whether the request was a direction from the individual or a request from the third party.  OCR is open to engaging with the community on ways that technology could easily convey this information.

Finally, we note that disclosures to a third party made outside of the right of access under other provisions of the Privacy Rule still may be subject to the prohibition against sales of PHI (i.e., the prohibition against receiving remuneration for a disclosure of PHI at 45 CFR 164.502(a)(5)(ii)).  Where the prohibition applies, a covered entity may charge only a reasonable, cost-based fee to cover the cost to prepare and transmit the PHI or a fee otherwise expressly permitted by other law or must have received a HIPAA authorization from the individual that states that the disclosure will involve remuneration to the covered entity.

May a health care provider withhold a copy of an individual’s PHI from the individual who requested it because the covered entity used the individual’s payment of the allowable fee for the copy to instead pay an outstanding bill for health care services provided to the individual?

No.  Just as a covered entity may not withhold or deny an individual access to his PHI on the grounds that the individual has not paid the bill for health care services the covered entity provided to the individual, a covered entity may not withhold or deny access on the grounds that the covered entity used the individual’s payment of the fee for a copy of his PHI to offset or pay the individual’s outstanding bill for health care services.

Can an individual be charged a fee if the individual requests only to inspect her PHI at the covered entity (i.e., does not request that the covered entity produce a copy of the PHI)?

No.  The fees that can be charged to individuals exercising their right of access to their PHI apply only in cases where the individual is to receive a copy of the PHI, versus merely being provided the opportunity to view and inspect the PHI.  The HIPAA Privacy Rule provides individuals with the right to inspect their PHI held in a designated record set, either in addition to obtaining copies or in lieu thereof, and requires covered entities to arrange with the individual for a convenient time and place to inspect the PHI.  See 45 CFR 164.524(c)(1) and (c)(2).  Consequently, covered entities should have in place reasonable procedures to enable individuals to inspect their PHI, and requests for inspection should trigger minimal additional effort by the entity, particularly where the PHI requested is of the type easily accessed onsite by the entity itself in the ordinary course of business.  For example, covered entities could use the capabilities of Certified EHR Technology (CEHRT) to enable individuals to inspect their PHI, if the individuals agree to the use of this functionality.

Further, a covered entity may not charge an individual who, while inspecting her PHI, takes notes, uses a smart phone or other device to take pictures of the PHI, or uses other personal resources to capture the information.  If the individual is making the copies of PHI using her own resources, the covered entity may not charge a fee for those copies, as the copying is being done by the individual and not the entity.  A covered entity may establish reasonable policies and safeguards regarding an individual’s use of her own camera or other device for copying PHI to assure that equipment or technology used by the individual is not disruptive to the entity’s operations and is used in a way that enables the individual to copy or otherwise memorialize only the records to which she is entitled.  Further, a covered entity is not required to allow the individual to connect a personal device to the covered entity’s systems.

More information is available here.

Posted in: Day-to-Day Operations, Electronic Medical Records

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Who’s Listening to Our EHR Issues?

Who You Gonna Call When Your EHR Sucks...the Life Out of You?

 

 

 

 

 

We hear more and more every day about EHR problems and physician dissatisfaction with performance and usability, and the way the federal government makes them use it. So, who should physicians complain to?

Of course you should complain to the vendor about usability, and complain in groups when possible. I’ve started several user groups in the past and have had success in communicating with vendors to improve their products. The key is keeping the User Group independent from the vendor, which takes committed volunteers.

In addition, you may want to complain to the Office of the National Coordinator (ONC) and hope that other physicians will do the same and there will be traction gained by many voices. The ONC has just launched an online complaint form for this purpose, but note, Coordinator Karen B. DeSalvo, MD only wants to hear about problems with certified EHRs.

Don’t know if your EHR is certified? Check here.

The American Medical Association (AMA) is also working on behalf of physicians with a campaign called “Break The Red Tape” which calls upon physicians to write about (or video) their EHR story. Even if you don’t plan to share your EHR story, be sure to click on the link and hear from real people.

Physicians (and their staffs) are overwhelmed with all the mandates. As a consultant, I no longer work with Meaningful Use, PQRS/VBM or PCMH. I refer practices to other consultants for these needs because I would rather work on what I think is meaningful in medical practice today – practice business models and strategies that bring more satisfaction to the physician and the patient.

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Posted in: Electronic Medical Records, Headlines, Learn This: Technology Answers

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Wearables Will Soon Be Part of Major Shift In Medical Practice

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

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.

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

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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New “One Patient” MU Rule Brings Relief

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Last week, CMS published a new proposed rule for Meaningful (MU). This rule strives to  “…align Meaningful Use (MU) Stage 1 and Stage 2 objectives and measures with the long-term proposals for Stage 3…”. In other words, make the program simpler and make it easier to achieve.

The proposed rule would simplify MU by:

  • Reducing the overall number of objectives;
  • Removing measures that have become redundant, duplicative or have reached wide-spread adoption;
  • Allowing a 90 day reporting period in 2015 to accommodate the implementation of these proposed changes in 2015, and possibly of the greatest interest to medical practice,
  • Remove the 5 percent threshold for Measure 2 from the EP Stage 2 Patient Electronic Access objective, requiring that at least (only) 1 patient seen by the provider during the EHR reporting period views, downloads, or transmits his or her health information to a third party.

This last one is extremely important as practices have spent much time and money trying to encourage patients to use their portals to fulfill the view/download/transmit requirement. As a patient, I understand this. I only use my PCP’s portal a couple of times a year, so I invariably forget my user ID and password (yes, I do know there are programs to store and retrieve these for me, but that’s a conversation for a totally different post) and it all ends up just being a big pain. My health is important to me, but I don’t have reason to get on the portal on a regular basis, and practices are finding out that many patients just don’t care to use the portal or don’t have a need.

More light reading on the proposed rule is available here in the Federal Register.

Posted in: Compliance, Electronic Medical Records, Medicare & Reimbursement, Medicare This Week

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Bringing Physicians and Patients Together Via Smartphone? Dr.Church Has An App For That!

Text to Doctor

I am always excited when physicians design products for other physicians because they “get it.” Here’s the tale of a Midwest physician, Dr. Fred Church, who has developed  a free app  to communicate one-on-one with his patients via email or text.

Mary Pat: Dr. Church, tell me how you came to design e-Consult My Doctor, an app that lets physicians and patients communicate with the ease of email and text in a secure environment.
Dr. Church: I suppose the axiom of “necessity is the mother of all innovation/invention” applies here. I saw a growing need and had a growing entrepreneurial passion to solve the problem for more physician-patient interaction between scheduled visits. I believe we are at the precipice of still greater demand for mobile connectivity and services in America.
The premise of private communications to enhance doctor-patient relationships is not a novelty, but how to do it in a HIPAA-compliant manner that is also is simple and convenient is a significant challenge. We are delivering an elegant smartphone app that uniquely understands a busy doctor’s and patient’s lives and works to serve them. We have created a utility that enables any doctor to be a concierge-service doctor and every patient to be the beneficiary of that great personalized care – care that is direct from the doctors that know them and whom they trust.
Mary Pat: You describe e-Consult My Doctor as a tool to augment the physician-patient relationship, not replace the traditional office visit. Can you give some examples of this?

Dr. Church: In no way is our communication management tool intended to replace the face-to-face interaction and assessment between a physician and his established patient.  We have terms of service that users will explicitly understand and agree to prior to participation. Doctors will not have to worry about this being crystal clear to patients. Most reasonable people understand that emergency situations need to be dealt with in-person and this tool is not intended to deliver emergency communications.   Example Scenarios: 

  1. “Doctor, can you give me an evaluation of this mole as I think it has changed since you last saw me for my physical? You told me to watch it and document it myself on my phone… should I be seeing you now or wait until my next physical?”
  2. “Surgeon, I am three days post-op and it’s Sunday afternoon and I’m scheduled to see you tomorrow for follow-up.  Can you take a look at these two pictures of my wound to tell me if I need to go to the urgent care or ER tonight before tomorrow’s follow-up? I’m not alarmed but a little concerned at how it looks and I want to have your opinion before my scheduled follow-up.”
  3. “Doctor, one month ago I described to you during Betsy’s well-child visit the rare sounds and behavior changes I was hearing and seeing from my 3 month-old daughter and felt like I was having difficulty adequately explaining it to you. Guess what, I was able to capture it on this video with audio.  Can you listen to it and tell me your opinion if I should be concerned about it? Should I bring her back in after you view this so you can examine her again and/or do more lab workup?”
  4. “Doctor, we talked about considering certain omega 3 supplements and I want your opinion on this particular supplement (see picture of label) from XYZ that the pharmacist recommended. Do you think it’s a good one also?  I appreciate your opinion before my next follow up with you.”

Mary Pat: Foremost in everyone’s mind is the privacy and confidentiality of texting and emailing – how does e-Consult My Doctor achieve HIPAA compliance? 

Dr. Church: Our smartphone app technology uses best practice standards for data at rest and in transit using AES 256-bit encryption. Doctors and patients will have a secure login to their app so that if their phone is stolen or misplaced, the data is still encrypted and cannot be viewed without a user’s password. If a user’s account is somehow compromised, administratively we can suspend his account, his e-consulting relationships, and access to the information between those relationships.

Mary Pat: Do you see this product replacing the traditional function of a nurse triage in the medical practice?

Dr. Church: Absolutely not. In fact, it is intended to offload the burden that triage is often overwhelmed with. Traditional healthcare will always need people to properly triage communications at a doctor’s office.  Unfortunately, high volumes and increased costs mean that calls are not always responded to in a timely way. Doctors need communication tools that are portable and flexible and this describes e-Consult My Doctor.

Mary Pat: Your software has some interesting features, including a mini-EMR or PHR (Personal Health Record.) Can you describe the benefits of a mini-EMR available from a smartphone?

Dr. Church: Because our solution is much less complex than an EHR (Electronic Health Record), a single adult patient user may keep and manage all of his dependents’ information on one app securely. Our well-designed smartphone app stores all related health event reminders, vaccine history, and PHR information. The PHR on our smartphone app is viewable/editable without the requirement of an internet connection, which is a clear advantage over EHR portals.  When patients participate in managing their information and updating their PHR data between visits, it makes it easier for intake nurses/staff during scheduled visits to make sure the EHR’s data is also reflecting recent changes that may be more current than EHR updates from various sources: other urgent cares/ERs, other specialty doctors, other health providers/doctors/sub-specialists (DDS, DC, DPM, etc.), hospitals etc. One of the main advantages of patients participating in their own PHR information is it will hopefully improve PHR accuracy, contribute to better patient compliance, and help serve both patients and doctors in traditional healthcare delivery.

Mary Pat: How does the documentation of the communication between the physician and the patient get back into the practice EMR?

Dr. Church: The app will allow for exporting content via PDF and both doctors and patients will have their own copy of e-consultation data on their apps. Doctors may elect to attach the PDF of the e-consultation interaction to their respective EHR if they believe it is important enough and pertinent to a patient’s long-term record. For example, several EHRs do not have the ability to import pictures, audio, and video content which this app will easily store for minimal convenience fees.  Additionally, a doctor can simply summarize the exchange in her next scheduled office visit’s documentation if she feels the content is important enough. This will vary on an individual case-by-case basis and will be up to the doctor’s judgment.

Mary Pat: Between the secure communication and the mini-EMR, e-Consult My Doctor sounds very much like a patient portal. Can your software replace a patient portal for a medical practice?

Dr. Church: The mission of our software is to deliver a different and simpler solution for convenient communication and to augment the functionality of an EHR’s patient portal. An EHR patient portal is valuable for a singular patient to see what his doctor’s EHR documents as his current information including labs, vitals, etc.  The e-Consult My Doctor app will allow direct one-to-one communication any time and anywhere the doctor and patient are willing to participate.  One of the foundational premises of our product is that a doctor’s extra time and effort should be rewarded directly by the beneficiary… like having pay-as-you-go access to their mobile phone or email for enhanced, personalized care between scheduled visits.

Mary Pat: You have essentially designed a product that allows physicians to be reimbursed for care that they have been previously providing for free. Some patients will appreciate the convenience and be willing to pay for the personal attention and others will think it is akin to the airlines charging for luggage! How do you answer those who think healthcare is already too expensive without any additional fees? 

Dr. Church: I’m amazed how many people are willing to pay for the $1,000 – $2000 per patient per year for 24/7/365 access that they may only utilize a few times a year. I personally know concierge doctors who are eagerly looking forward to our HIPAA-compliant solution that will help them achieve better work-family life balance with our communication management tool.  We believe our smartphone app will bring a revolutionary solution that allows every doctor and every patient to participate in a concierge e-consulting relationship at a potentially lower price point. Our solution eliminates the middleman with a convenient and simple solution at a very affordable price and payment is directly and immediately received by the doctor.

Mary Pat: When will this product be available on the market and what will it cost physicians to purchase?

Dr. Church: The anticipated market delivery date is November 30, 2013. The app will be free and the basic subscription level will also be free. Users will be given a limited amount of secure storage space and may upgrade to larger amounts based on their individual needs. We will also offer a premium subscription level that will afford a larger secure space allotment and additional valuable service offerings. Our app will offer a pay-as-you-go, transactional model for the basic subscription level and a fixed-price price point for the value-minded user who wants more. Fred Church

Mary Pat: How can readers get in line to try your app?

Dr. Church: They can go to  http://e-ConsultMyDoctor.com and sign up for pre-launch information and be the first to try it out.  We invite physicians who want to be beta-testers!

Posted in: Amazing Customer Service, Electronic Medical Records, Innovation, Learn This: Technology Answers, Practice Marketing, Social Media

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Are Patients Lost in Translation? An Interview With Dr. Charles Lee of Polyglot

Universal Medication Schedule (UMS)
Sometimes you find the most amazing things in your own backyard. In Research Triangle Park, NC, I found the wonderful Dr. Chuck Lee, President and Founder of Polyglot. I was bemoaning the lack of good translation software for healthcare and Sims Preston, CEO of Polyglot, contacted me on LinkedIn and invited me to see their product Meducation. I was fascinated by Dr. Lee’s story and I think you will be too.

Mary Pat: Dr. Lee, you had a very personal reason for starting a healthcare company that focuses on communication in different languages, didn’t you?

Dr. Lee: First, as a clinician, I’ve always believed that we need to help all our patients understand their health information so that they can make better health decisions.  To me, it’s just common sense that better health outcomes starts with better informed patients.  The challenge is that much health information is not usually written with the patient in mind.  It’s often written in high grade reading levels using medical jargon, and often only available in English.  If it is available in another language, it’s usually only in Spanish.

About one of every three US adults has some difficulty understanding health information and almost 30 million struggle with the English language – almost 10 percent.  Because I am a first generation Korean immigrant – I came to the US when I was 7 years old – I saw how my grandmother struggled to understand how to take her medications.  This is one of the reasons I became interested in this issue.

Mary Pat: How did your own experiences drive your vision for your company ‘Polyglot”?

Dr. Lee: It became very apparent that other HIT companies had little interest in serving the needs of minority populations – they said that there’s not much money in it.  They said it was too difficult, too costly, and that the market wasn’t big enough.  If you look just at the numbers, yes it may not make sense – but how do we continue to ignore almost 10 percent of the population – thirty percent if you count low health literacy! That’s when I decided to form Polyglot Systems to show that creating technology to support language and cultural needs of underserved populations doesn’t have to be hard or costly.  If our small company can do it, the big guys will have no excuse.

Mary Pat: Can you talk about the state of healthcare communication for non-English speakers in the United States today?

Dr. Lee: Just think about what it would be like for you if you were in another country and they didn’t speak English.  If you got sick and needed medical care, would you know how to read the signs? Know where to go? Know what forms you are signing? Know what the doctors were saying? What your treatment choices are? Or how to take your medicine if the bottle didn’t have English instructions?  That gives you a glimpse into what it’s like for non-English speakers in the US.

After I saw my grandmother’s pill bottles with instructions written in English that she couldn’t read, I became aware that this was not an isolated incident.  So I asked myself this: How many medication errors are caused by language barriers? Last year there were about 4 billion prescription written – that’s not including over-the-counter medications.  Just based on statistics, that would mean about 400 million prescription were given to patients who are limited English proficient.  The need was obvious.  If you include English-speaking patients who have difficulty understanding health information, this number approaches 1.5 billion prescriptions.  Have you seen some of instruction they give you at pharmacies? Even I can’t understand what much of it says.  Also, a lot of the instructions are printed in such small print that I had a hard time reading them.  So one of the features we built into Meducation was larger font support for elderly and visually impaired patients.

Mary Pat: It seems that the timing for Meducation is perfect based on the recent emphasis on patient engagement, eliminating waste in healthcare, and increasing medication compliance. How does Meducation address these?

Dr. Lee: For me, it all comes down to common sense.  We submitted our first grant proposal to the NIH for Meducation almost 10 years ago – when all those issues you mentioned should still have been issues back then, they just weren’t popular things to talk about then.

Healthcare statistics usually say that a minority of the population utilizes the majority of our healthcare resources. This includes those with heart disease, diabetes, CHF, etc.  Do we ignore them because they are the minority? Of course not.  I bet you that a significant portion of the patients with heart disease, diabetes, CHF have low health literacy and/or language barriers.  If we can make even a few percent improvements in these populations, wouldn’t it be worth doing? This just made sense to me.

I sometimes like to compare our healthcare system to the cable industry.  The cable companies spend tremendous amount on research and expense for laying fiber-optic cables in streets in front our homes.  But unless we can connect the home to the corner – what they call “the last mile” – it means nothing.  It’s the same in healthcare. Unless patients understand and act to self-manage their own condition, all our advances in healthcare will have little effect.  Patient engagement is the last mile.

Mary Pat: How does Meducation interface with EMRs?

Dr. Lee: This is our biggest challenge now.  We’ve developed APIs to make it easy for EMRs to request and download our multi-language patient information.  The difficulty has been getting many of the EMR vendor’s attention.  They are so preoccupied with Meaningful Use and certifications that they have paid little attention to patient education and engagement.  But I predict that this will start to turn around as reimbursements will force them to do so.

Mary Pat: Meducation also has videos with demonstrations on medication techniques. What types of videos are available and how can patients view them at home?

Dr. Lee: The videos focus on techniques for taking complex medicines such as inhalers, eye drops, etc., so the patients are actually benefiting from the medicine and not wasting it by using it incorrectly.  We want to expand these to include other techniques such as wound care, port care, etc. in the future.  The demos are free to patients if their healthcare provider or pharmacies use Meducation. Patients receive a card with the website and video ID so they can view it as often as they like at home.

Mary Pat: Meducation uses a universal graphic that shows patients when to take medication which seems like a great idea for communication despite the language the patient speaks – can you talk about this?

Universal Medication Schedule (UMS)

Dr. Lee: Yes, this is called the Universal Medication Schedule (UMS).  It was developed by a group of health literacy researchers at Northwestern University and Emory University.  It breaks up medication times into four times of day: morning, noon, evening, and bedtime. Over 90% of all daily meds can fit into this schedule and make taking medicines much easier to follow.  The Institute of Medicine (IOM), the American College of Physicians (ACP), and most recently the National Council for Prescription Drug Programs (NCPDP) have recommended its use.  I really like it because it helps patients remember with pictures if they have difficulty understanding written instructions.

Mary Pat: You use the word “affordable” as part of your mission for Polyglot. I am always seeking solutions that are affordable in healthcare. Can you talk about the cost of Meducation for a solo primary care physician?

Dr. Lee: You know, I wish I could give this away for free to everyone.  But we have to make this a sustainable effort.  I’ve seen so many good projects die because they didn’t have a plan to keep it funded and going beyond the grant or some other funding source.  This is one of the reasons I left academics to start our Polyglot.  That being said, our products need to be affordable for front line providers – safety nets and federally qualified health centers (FQHCs) – because they interact most often with underserved patients – and have the least financial resources.

For provider practices, the subscription list price is $50/mo for unlimited use.  That’s less than $2 day for the ability to print instructions for all your patients in 16 languages – including elderly English-speaking patients in larger fonts.  As a comparison, $2 is about what it cost to use a telephone interpreter for about 1 minute.  Mary Pat, we would be happy to provide your readers a discount on Meducation.  Just have them contact me at lee@pgsi.com.

Mary Pat: What other projects do you have planned for the future?

Dr. Lee: I think the opportunities to improve communication for patients are only limited by our imagination.  There is so much that we can do create quality literacy and language solutions and deliver it inexpensively to a wide audience.  We are currently working on a solution to reduce hospital readmission through simplified multi-language discharge instructions that can be individualized for each patient.  We are adapting this for use during home care visits as well.

Charles Lee, MD, President and Founder of Polyglot
Dr. Lee: Polyglot Systems was founded in 2001 to help our US medical community care for the 26 million Americans who are unable to communicate effectively in English. Our mission is to deliver solutions that eliminate communication barriers at every stage of the medical encounter – improving the experience of both the patient and health care provider.

For more information about Meducation, Dr. Lee invites you to visit the Polyglot websiteHe is extending a discount on Meducation to readers of this article – please contact him at lee@pgsi.com.

For another post on communicating with patients, read my post “Can Patient Safety Be Improved By Asking Three Questions?” here.

Posted in: Amazing Customer Service, Compliance, Day-to-Day Operations, Electronic Medical Records, Innovation, Quality

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Start PQRS Now! It’s Not As Hard As You Think

Getting Started with PQRSNOTE: CMS has just added additional presentations of the webinar below – please check the end of the article for added dates. MPW

What is PQRS?

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Posted in: Collections, Billing & Coding, Compliance, Day-to-Day Operations, Electronic Medical Records, Finance, Headlines, Medicare & Reimbursement, Quality

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Are Your Physicians Crying About Your EMR?

A new report suggests that 2013 may be the year of the great electronic medical records (EMR) vendor switch given that many EMRs are falling short of providers’ expectations.Crying About An Underperforming EMR

To come to that conclusion, Black Book Rankings polled roughly 17,000 active EMR adopters – and found that as many as 17 percent may switch out their first-choice EHR by the end of the year.

The reason: In light of Stage 2, provider demands are increasing, and EMR users are reporting that many EMRs aren’t living up to expectations. In fact, those polled cited numerous cases of software firms underperforming badly enough to lead them to lose market share.

As a result, 31 percent of survey respondents indicated they were “dissatisfied enough” with their EMR to consider switching. Of those users, the reasons cited for the potential switch were as follows: (more…)

Posted in: Day-to-Day Operations, Electronic Medical Records

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