Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities
When will the ICD-10 Ombudsman be in place?
The Ombudsman will be in place by October 1, 2015.
Does the Guidance mean there is a delay in ICD-10 implementation?
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.
What is a valid ICD-10 code?
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?
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.
What is meant by a family of codes?
“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.
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?
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.
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?
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/.
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?
Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.
Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?
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.
If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?
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.
Does this added ICD-10 flexibility regarding audits only apply to Medicare?
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.
Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes?
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.
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?
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.
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:
What goals did you accomplish since your last evaluation (or hire)?
What goals were you unable to accomplish and what hindered you from achieving them?
What goals will you set for the next period?
What resources do you need from the organization to achieve these goals?
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.
UPDATED INFO: These recorded webinars are now available here.
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:
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!
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:
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.)
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%?
“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.
At 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.
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.
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!
Medicare distinguishes between authorized officials and delegated officials on their enrollment forms and many people wonder what the difference is.
Authorized Official Definition
An authorized official means an appointed official (i.e. chief executive officer, chief financial officer, general partner, chairman of the board, or 5% or greater direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s enrollment information in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
Authorized Official Authority
The authorized official is the only individual that has the authority to sign the initial CMS 855S application. By this signature the authorized official agrees to notify the Medicare program contractor if any of the information on the application is incorrect or untrue. Also, the authorized official agrees to notify the NSC of any changes within 30 days of the change (Supplier Standard 2).
An authorized official is the only individual that can add and remove delegated officials.
Suppliers may have as many authorized officials as desired as long as the individual meets the definition of an authorized official.
Delegated Official Definition
Delegated officials are persons who are delegated the legal authority by the authorized official to make changes to the supplier file. A delegated official must be a W-2 employee of the supplier or an individual with 5 percent or greater direct ownership interest in, or an individual with partnership interest in the enrolling supplier. If the delegated official is the managing employee, this individual must be a W-2 employee and the NSC may request proof this individual is a W-2 employee.
Delegated Official Authority
A delegated official can make changes or updates to the supplier file, such as address changes or the addition of a part owner.
The delegated official may also sign and submit the CMS 855S to enroll additional locations, revalidate or reactivate an existing supplier.
A delegated official may not delegate its authority to another individual. Only the authorized official may appoint someone as a delegated official
A delegated official may not sign the initial CMS 855S application for the initial location.
A supplier may have as many delegated officials as desired as long as the individual meets the definition of a delegated official.
There is a lot of advice out there on making the transition to ICD-10.
Your medical practice may already have taken some of this advice and you are well on the way to readiness for I-10. But if you’ve not done anything yet for the transition, this article is for you. I’ve distilled all the blah-blah-blah down into three easy steps that any practice can follow to embrace the change.
1. Do You Need More Software Support?
There is no question that most everything hinges on your EMR and billing system’s management of ICD-10. Your vendor may say the system is I-10 ready, but what does that really mean?
Ask your vendor these questions:
Are ICD-10 codes available in the system now? If not now, when?
Can the providers and staff rehearse using I-10 inside the system by dual coding and assigning both an ICD-9 and an ICD-10 to services without having the I-10 drop to the claim?
What support, if any, does the system give for choosing the right ICD-10? Is there any type of translator or crosswalk between I-9 and I-10?
After October 1, 2015, will the software have the ability to use an I-10 or crosswalk from 10 to 9 if the payer does not accept 10? It should! Physicians and coders/billers should not have to look at the patient’s payer of record to decided which one to use, nor should they require you to change the I-10 to I-9 on the back end. It is very doable for software to crosswalk from 10 to 9 for you.
If the software supports getting to the most specific ICD-10 possible, not just picking the first one that vaguely matches, choosing the I-10 should be straightforward. If your software does nothing more than save the I-10 codes you choose to a favorites or a pick list, then you will need a standalone piece of software called an “encoder.” Hospitals and mega practices have been using encoders for years to help navigate the maze of Medicare local and national rules.
Practices without sufficient support from their EMR/Billing software will need an encoder that can not only suggest possibilities for ICD-10 codes, but can also assist in finding the right code from a series of words algorithmically ordered. (If you want to know which encoder is my particular favorite, send me an email at email@example.com.) Encoders also usually have additional benefits that your billing software or claims scrubber may not have such as CCI edits, modifier rules, global period and wRVU information.
Example of the drilling down to the correct I-10 diagnosis assisted by an encoder:
Which bone? Which part of the bone? Laterality?
Type of fracture? Open, closed, displaced, non-displaced?
Encounter? Initial, Subsequent, Sequela?
Associates diagnoses, conditions?
2. Could Documentation Be Brushed Up?
In hospitals, entire teams of people (Clinical Documentation Improvement staff, usually nurses) are dedicated to making sure that the documentation can support the specificity of the I-10 code chosen. This is especially important for the hospital side of reimbursement.
In the hospitals there are often silos between the service providers and the coding review and billing staff. In practices, we have the good fortune to be able to reflect on the documentation once the I-10 code is chosen, and clarify the documentation on the spot if needed.
Some easy ways to make sure your documentation is as complete as possible to support the I-10 code are:
Think of MEAT when you document. Every condition in your documentation should be described as Monitored, Evaluated, Assessed and/or Treated. If the patient has an existing diagnosis that you did not address during the visit, don’t put it in the documentation or on the claim.
Use “due to” or “manifested by” for each problem that you describe, if you know that information.
Change/improve your EMR templates (or paper progress note format) to accommodate the points above.
3. Are You Ready for Cash Flow Interruption?
You’ve heard this for years and it remains a legitimate concern. If there is any problem with claims processing OR if you are not using ICD-10 properly causing denials, there is a good chance your money from insurance companies will slow down or even dry up for awhile. I suspect that insurance companies may use ICD-10 as a handy excuse to delay payment regardless of the plethora of other excuses they have to choose from.
Predictions on the cost of ICD-10 fluctuate wildly, but here are the places you are most likely to feel the financial pain:
If your EMR/Billing system wants you to pay for an upgrade to your software to compensate them for the money they’ve spent upgrading their software. Since the delay, I’ve heard of fewer companies requiring a special payment for the upgrade.
Reduction of productivity based on time spent to choose an I-10 code:
Any manual form in your practice that uses ICD-9 will need an ICD-10. How will you find those codes?
Physicians who choose codes through their EHR will need software support to find those codes. Because there are so many more codes due to the specificity of each code, it will take a while to get the hang of it if you are not using an encoder.
Inability of your clearinghouse to send claims. Unless you are directly submitting claims to any payers, your clearinghouse has probably tested (end-to-end, please) with payers. Ask your clearinghouse who they’ve tested end-to-end with and what the results were. If things really bog down with CMS, they may grant advance Medicare payments to physicians that are not receiving payments due to the ICD-10 transition.
Delay in payment from any payer due to ICD-10 general chaos.
Keep in mind that a lot of the hoopla over ICD-10 has been on the hospital side. Physician practices are very lucky in that we use CPTs for reimbursement (at this point), not diagnoses. This is a huge change for the hospital/facility side, but much less of a transition for medical practices. We are hoping that physician practices will have less impact to their bottom line, but you should be ready with a line of credit or some extra funds in the bank for this possible rainy day. Starting today, practices that make distributions to owners quarterly may want to scale this back until the smoke clears.
Resources to Help You:
AHIMA (American Health Information Management Association (AHIMA) has an a nice set of tools relating to the adoption of ICD-10 here. Not all tools are available for non-members.
The AAPC has lots of high-quality offerings here, most for members or for purchase by nonmembers. Although it was written for the original 2014 transition, here’s a good article to review for the creation of an ICD-10 superbill, or just to review your top I-9s and translate them to I-10s.
Your software vendor, claims clearinghouse and specialty society should also have ICD-10 tools.