you're spending the total time and have these other documentation elements, you know, there just has to be a status change. So you would need to clearly document the decline or the change in patient condition or kind of that continuing effort is what the FAQ says. So this next slide is not related to advanced care planning, I apologize. This is what my documentation template is for TCM. And you have this in a tools and tip sheet handout. Again, I would use these bullets as what's in the template and then you fill in the blanks with the specific clinical details. But these are also, you've heard me probably mentioned tools and tip sheets. Focus on your workbook first because we've made it a lot easier and put a lot of great resources in that workbook. But if you haven't visited our agency intelligence tools and tip sheet page, we have very much more plans to to keep adding to that in 2021. We have clinical practice management sample patient forms. We have a lot of great information on there. So I encourage you to take a look at that if you're not familiar. Next slide. So again, just sample smart phrases. Make sure your providers have some scripting for how they go about that consent. Your templates. Most importantly, document your time. I've put in some examples here for you. For the sake of time, I'm not going to read this through to you. I'm just going to move on to the next slide. Why do you want to get paid for advanced care planning? Because it's $86. Again, in the fee-for-service, especially in 2021, get paid for all the work that you do. We are moving to a value-based healthcare system. The time is not here yet, but I totally look forward to the day where I don't have to talk to you about fee-for-service revenue opportunities and we can focus more on quality documentation and other things. But right now, if you're under fee-for-service, you really have to be doing these things to survive and have a sustainable practice. Next slide. So any questions on advanced care planning before we move on? Or comments? Anyone want to share something that's worked really well for them? I know we're running out of time. So again, I'm talking about a lot of different services here. What I want you to realize is you can't build all of these services. Think about what makes the most sense for your practice model and then pick those services. Prolonged services without direct patient contact. I'll revisit this at the end, but if we go to the next slide. And yeah, so to answer Marla's question, I think it's really important to think about what makes the most sense for your practice model and then pick those services. Prolonged services without direct patient contact. I'll revisit this at the end, but if we go to the next slide. And yeah, so to answer Marla's question, do you need a 25 modifier when you code E&M and ACP? Yes. In almost all payers, if you do, I would still check with your local Medicare administrative contractor. I had one region tell me one time their MAC didn't require it. But for the most part, you should need modifier 25. 99358 is yet another option of how you can get paid for non-face-to-face time with patients. It's another time-based service. This one you have to spend, because it says the first 60 minutes, getting past the halfway point, like I mentioned, is a minimum of 31 minutes. Non-face-to-face time, but it has to relate to a face-to-face visit. So the specific examples are extensive medical record review before you see a new patient, or if you have a family care conference that was related to a visit. Those would be examples of when you could use prolonged services. But that non-face-to-face discussion, that alone has to be at least 31 minutes for you to bill for it. That time, the 31 minutes, it could be before the E&M visit. So again, preparing for a new patient visit. It could be after it. Maybe you had an extensive conversation with the son who lives out of state after the visit. Or it could be on the same day. Can it be combined? If it's all on the same calendar day, yes. But this is non-face-to-face time. So you just have to be careful with that. It's also bundled with chronic care management. So if you're billing for chronic care management, you're really probably doing a better job getting paid for all this non-face-to-face time. But some practices may say, OK, now, rather than CCM, I'm going to focus on prolonged services and TCM or something other. This is where you want to keep this in your back pocket. You do have to have start and stop times, I do want to say. I looked at the Medicare claims processing manual a while back when we were going back and forth about these codes. They want start and stop times for prolonged services. So you should have start time, end time of your conversation, your total time, so at least 31 minutes. And then if we go to the next slide, supporting documentation of how it really went above and beyond that visit. You know, the caveat, prolonged services, unfortunately, kind of has a lot. Again, don't let these caveats scare you. Just know the regulations, know the kind of care and the services and the time your providers spend, figure out what makes the most sense, and then build a compliant template. There is an add-on code, 99359. If you spend a minimum of 76 minutes, that would be pretty extensive, but it's possible. You could certainly do that. And again, this is non-face-to-face time that has to be related to a face-to-face visit. The difference with those care management services, like I talked about, the chronic care management, those aren't tied, or CPO, those aren't tied to a face-to-face visit. They're just all that non-face-to-face clinical care coordination time. This is tied to a face-to-face visit. That's really the difference with this service. Next slide. So, bringing them all together, start and stop time, total time, you know, again, a description, what did you do during that 31 minutes? What kind of medical records did you review? What are some clinical details? If you're reviewing medical records for a new patient visit, what are some things that you're going to be thinking about, or what was the details of that family care conference? The caveat on top, again, a lot of this, I just wanted you to have all the regulations at your disposal. What they're essentially saying is, if you spent 31 minutes ahead of time of the visit, and so because of that, you only spent 15 minutes with a face-to-face visit, and you're billing a lower level of service, well, you really shouldn't be billing for prolonged services, because that didn't go above and beyond the kind of pre- and post-work that they consider bundled with an E&M service. So, these are really extended visit times. This isn't an every patient, every time thing. Next slide. I always, I'm a big fan of documentation examples. Dr. Cornwell was kind enough to kind of help with this one here on how he'd do it. So, again, you know, just thinking about this. Tom, feel free to chime in if you want to, I know you put the comment in the chat. Did you want to say anything about? I know, but this is just an example. This is what I would do before the visit. So, you talk about excellent care. So, even before I saw the patient, because we would get this information ahead of time, I've not seen this patient. This is the day before, and you can see my 32 minutes, but I would put in there the IADLs, there was a smart phrase that I would put in these categories, and then, you know, put in, you know, PCP, cardiologists, you know, we asked what their faith is, we asked what they're proud of for all of our patients. Next slide. I think, is there one more, or is it just this one? I just put this one in there. Literally, I would list all their, in addition to that information, I would list each one of their medical problems that I could find in the chart, what medicines they were on for it, when their last echo was, what their BNP was, you know, you know, whatever it was, I would add in there. And then, I would write in questions like, on PPI, you know, why are they still on it, you know, or if there was a medicine that I did not have a diagnosis for, I would write myself notes. And so, I would spend, as I wrote, I didn't know that was coming, I would, 95 plus percent of my patients in 2019, every new patient, I added $115, well, here it says 114, $114 to every new patient, because I would do this remarkable care in terms of spending time getting to know them before I saw them. So, it was great care, but also, I was rewarded financially for doing it. Yeah, thank you. I think it just helps, again, you know, we're providers, we want to, you know, just provide, you guys are providers, sorry, not me, like, you want to just provide great clinical care. Why do you have to be bogged down with all of this billing? The way that I like to look on it, you know, if you're trying to look at the silver lining or the positives, doing really good things is going to, number one, help you have a sustainable practice so you can actually be there to provide that excellent care to these patients and create such great access. And then, potentially, even add new services or grow, because you have a revenue stream that's sufficient enough to do this. Just remember, this cannot be billed in conjunction with chronic care management, so a lot of practices just kind of skip this code if they're doing really good CCM for all their patients. Next slide. So, prolonged services, non-face-to-face, that's what we just talked about, right? What about when you spend extensive time in the home, face-to-face with the patient and caregiver? And the face-to-face codes, because they're not non-face-to-face care management, they don't have all those bundling headaches where you can't combine them with other services, they're generally a lot easier. So, just want you to know, if you can go to the next slide. This is a little hard to read. It's blown up in your handouts. My rule of thumb is 90 minutes. If you spend 90 minutes in the home with the patient, you should be billing on time and adding prolonged services. You can probably make the case for how that was dominated by counseling and coordination of care and how you exceeded the E&M threshold. You could bill 99350 and 99354 if you spend a minimum of 90 minutes in the home. I like to think of it, you know, just if prolonged services face-to-face, you know, yes, technically you can bill it with a lower level code. I've seen some denials that way when it doesn't exceed the E&M threshold. So, my rule of thumb for really using this is when you're having extended in-home, all direct patient and caregiver time. And then your documentation needs to support how did you spend that time? Why was this patient so complex? What were all those things that you talked about that made you spend that 90 minutes in the home? Next slide. And then, again, just the new patient visits and the different time thresholds. So, you have these. Also, if you didn't attend Essential Elements and you feel like you need a refresher, look at these slides. You know, many of you, maybe if you did clinic work way back, remember getting cheat sheets for your office visit codes? What does it mean to have, you know, the level of history, exam, and medical decision-making? This kind of defines it for you and gives you that cheat sheet. So, I would encourage you to kind of look at this, maybe check yourself on a couple notes if this is pretty new to you. All right. So, if we move on here. The last service I'm going to talk about, again, you're not billing everything that we're talking about today. You're taking away what's most aligned with your care. But pretty much, how are you going to get paid for all the work that you're doing with these patients so you can have a sustainable practice? There are a couple codes for anti-coagulation management. These are bundled with, yeah, chronic care management, again, and TCM as well. You can't bill this in transitional care management within the same calendar month because they consider you managing the INR as part of the transition. So, it may not be the best opportunity for you, but at least wanted you to be aware of it. If you move to the next slide. There's two options here. The first one, which is nice because it could be your clinical staff under your supervision, is the initial setup and training when the patient is set up on a new home INR monitoring. Again, it's not the biggest bang for the buck. And these are the documentation requirements. But if you're setting up a patient on a new home INR monitor, you can bill this too. Obviously, as a provider, it's billed under you and you're doing some initial training. Next slide. This is the one that can be more fruitful if you make this part of your business model. So, if you're doing INR management for your patients and you're taking the time to, like you all will be, review their INR, schedule the next test, go over any dosing instructions, there is a code to bill for that. I believe I have the reimbursement on the next slide, so you can see how this adds up. So, again, 93793, that extra $12 for INR review. If you were doing that and a lot of prolonged services, that might be a good face-to-face business model. I personally think that care management services and capturing more of your time as a whole is a better bet, but I wanted you to at least be aware of that. In your handouts, another thing, again, we talked about a lot of different services today. If you go to the next slide, please use this next resource as your cheat sheet. The advanced coding opportunities handout, everything that we just talked about, these guidelines are summarized here. When you're going back to your provider team, especially if these are new to you or if this is new to you, make yourself a cheat sheet or have this be your cheat sheet. Give yourself some use cases and build those templates. Make a plan for how you can build these services easily and not have to remember all of their requirements. I also specifically wanted to call attention to, we didn't talk about it today, but I have the requirements in this handout. There's a CPT code for cognitive assessment and care planning services. It does have pretty extensive requirements, but essentially what it is is if you have a patient with a cognitive impairment, who you're trying to really diagnose the stage of their dementia and develop a care plan for, there is a reimbursement for it. Let me grab my cheat sheet so I can tell you how much it pays. The reason I'm mentioning it is because that also, with TCM, cognitive assessment and care planning, and annual wellness visits all got a pay increase in 2021. If we don't postpone budget neutrality, billing transitional care management, annual wellness visits, and cognitive assessment and care planning is one strategy you can take away to try and build your business model and help be sustainable, because those all got pay increases along with the office visit code set. Next slide. Next slide. Just some resources. Amanda mentioned the listserv earlier. If you don't know who your MAC is, this is how you find out. Every local area has a Medicare administrative contractor. They may come out with more specific coding guidelines and policies. You should have your practice managers or your billing team follow those and know how to find those resources. The other resource I really like, next slide. Is the care management site. If we go to the next slide. The CMS care management page has fact sheets on advanced care planning, behavioral health integration, chronic care management, transitional care management. I expect telehealth and some other things to be added to here. Know this page when you're looking at the CMS requirements or if you have kind of like one of those one-off questions, take a look at the FAQs and that should really help you here. And I think that brings me to the end of our presentation. You go on. Thank you, Brianna. That is just so much information. I'd like to ask all faculty to be ready for the last session of the day. And that's our Q&A. So please feel free to unmute or write questions in the chat. Thank you. Hopefully I didn't bore everyone to sleep with coding, but I thank you for hanging in here in the past two days. We're so excited. Like I said, I look forward to the day I don't have to sit here and talk to you about fee-for-service billing. Value-based care is the future. Start preparing for it now. And Brianna, there was a question about when to bill the 99358. Oh, yeah. Thank you, Tom. That's a good question. So it needs to be billed out on the same claim as the E&M face-to-face visit. Otherwise, you'll run into some back-end billing denial. So they can have different dates of service, like the 99358 in Tom's example. So let's say he saw the patient today, but he did the work yesterday. You know, they can have different dates of service on the claim not line, but they should be billed out together. So just work with your billing company or when you're billing the claim, you know, hold that non-face-to-face charge till you do the E&M visit. There's also, again, I know this is probably mumbo-jumbo to clinical folks, but there's ways you can set kind of that automated process up on your billing system, your revenue cycle management system, where it holds in a queue. It's called a charge review error kind of thing, where it would hold that charge for you. Or you make someone responsible for that. I used to tally that all up for Tom and Paul when we did those. So Melissa, Michelle, I don't know, did you guys, did you have questions like from the past two days that you wanted to read to people? Or do we want to just open up the mic? What do you guys like to? I'd open up the mic because I honestly think we've covered all the questions. Well, and we'll let you all tell us if we haven't. If you asked a question in the chat at some point in the last two days and we haven't addressed it, now is your time. Please ask. Okay. On the TCM, just clarification, is it just the follow-up call within two days and then visiting the patient within seven to 14 days post-discharge or is there something else? Yeah. So there are that list of non-face-to-face and face-to-face. Essentially, those are the two big buckets, right? The list of non-face-to-face services, the other requirements that you have to build into your templates is like, did you review the discharge summary? Did you do a comprehensive medication reconciliation? Did you coordinate any home and community-based services? Did you follow up on the need for any follow-up orders or testing that is done as part of the hospital? All of those things you're probably doing already, but that's why for TCM, you just want to have templates for that interactive contact call. That's where I'd use that non-face-to-face list I gave you. And then in your face-to-face note, build a template with those face-to-face bullets that I gave you to show that you've done all of those things. But essentially, yes, you're getting notified that the patient had a qualifying discharge. You're making that interactive contact call within two business days and you're seeing the patient within seven to 14 calendar days. And there was a question in the chat about, can we add 99358, which is the prolonged services non-face-to-face, to our home visit note as well and just bill for them both if we put in the statement in the face-to-face notes as to what we use the 993 and we bill both on the same encounter? So you could, technically. A lot of compliance departments would probably rather have that separate, but you could. The 99358, just remember, that's not your direct face-to-face time. So if you're putting it in your note just for the sake of simplicity, what was the date of service? What was that total non-face-to-face time? And really specific, how that went above and beyond. It was not related to what you did in your face-to-face visit. Most people like it as a separate telephone or care management encounter, just so you can really show that the work was separate and distinct. But it's not necessarily wrong to put it all together if that's easier for you as a back-end process. So I'm sorry, and I may have missed this also. But so combining, let's say, the prolonged provider time where, like Dr. Conwell said, reviewing everything, documenting the medication reconciliation, let's say on a patient that you're about to see after discharge, right? And then let's say you go to the home then two days later, and there you can build the TCM. But also, just like you said, it needs to be very distinct. Otherwise, it's like double-dipping, right? Otherwise, you're putting the provider time. This is really all meant to be built under TCM, right? And even a separate E&M code is only to be built separately if you can justify that there was like a different medical issue separate from the transition that you addressed, correct? Yeah. So transitional care management was recently just unbundled with prolonged services. But yeah, so the TCM, like they're expecting you're managing transitions and doing all that. Prolonged services is really when you go above and beyond, like for an extensive sort of visit type, right? But you just, what you said was a key word was double-dipping. That's why that documentation being separate and distinct helps because they're trying to make sure that you're not double-counting time and that you really did document separate work assets that were above and beyond that show that you should get medically necessary reimbursement for those services. The magic words that CMS likes to use for prolonged services specifically is it was above and beyond the typical time and effort a provider would spend on an E&M service. So how are you going to support that through documentation? Yeah, like calling the three consultants that the patient was admitted under separate, right? And talking to each of them individually. Absolutely. Yeah. So, I mean, we do that. So yeah. Okay. And so I'll just, I just want to add. So, you know, Dessa, in terms of that point, so we all, you know, a lot of us do chart prep, you know, because we need to know, do we need to bring a G-tube or what labs are we going to do? You know, what equipment do we need? And so I think in a home-based primary care, we do a lot of chart prep. And so basically, you know, I will start my note with this 99358. And so what you saw was actually starting my note for the day, but I need to show Medicare what work I did for this 99358. So after I prep my chart, I would actually copy that and then put it into either a telephone note or Epic has this thing called a non-face-to-face note. So that way, if Medicare ever questioned what I did for that 31 minutes, I have it separate because once I see the patient and I start adding, you know, so I'll say, you know, so I would actually like cut and paste the discharge summary. Into my follow-up sometimes, because I wanted to go over it with the patient and then I would add notes to it. And so once you see the patient, that note's going to change. And how does Medicare know what you did before the visit and what you did at the visit? So that is what, what I did. And in the Melissa's point, what, what, what Medicare means is if we do so much prep work that we go and see the patient for their TCM visit, and it only takes us five minutes because we did all this prep work. Medicare says you can't count both because you did all the work ahead of time. That never happens, right? When we do the prep work on these complicated patients, we still spend a lot of time at the visits, you know, confirming everything. I don't know what you're talking about now. Yeah. I mean, you know, so, and I'll stop there. So I hope that helps. Let's say I go see the patient within that seven to 14 days post-hospital discharge. And then the following week, or maybe two weeks later, I go back to see the patient for something like an acute visit. Is that still within that TCM or that's a different visit? So say that one more time for me. I'm sorry. What are you doing out at the separate visit? Okay. So let me say, once I go see the patient within that seven to 14 days post-hospital discharge, then a week or two weeks later, I go back and see the patient for an acute visit. Is that still within that TCM timeline? Yeah. Thank you for clarifying. Sorry. So you could bill a separate, you would bill a normal E&M visit, either a home or domiciliary code for that acute visit that you saw the patient for. So TCM is a 30-day service period. What you have to watch for there is readmissions. If you have a medically necessary separate and distinct follow-up E&M visit, you can still bill for it. What you have to watch is if you have a patient that was readmissioned and then you're doing two post-discharge visits within a 30-day period again. But if you're doing a separate and distinct E&M visit, you can still bill for that. Again, TCM is a little confusing, but all of that work that you're doing within that 30-day service period is all of the things you're doing for good transitions to avoid hospitalizations. TCM honestly really just comes down to good templates because I've done a lot of auditing in TCM too. And it's like you guys are doing great work, but you can't prove that all that non-face-to-face work and all those specific activities that they want done were done really without templates. But yeah, so Fran, if you saw the patient for a post-discharge visit, but they needed a medically necessary follow-up in two or four weeks, that would be separate than your post-discharge visit. You would bill a normal E&M when you went and saw that patient again. All right. Well, we are just about at 4.30 Central Time. And I just have a few closing remarks. And this is sometimes my favorite part of this workshop because I get to thank people. And I want to thank our staff who have been working behind the scenes for months, Danielle and Michelle. And Laszlo and Erica and others back at the office that aren't on the call. They've worked tirelessly to put this together. And I want to thank you. Thank you, our faculty. We always talk about how mission and service-oriented home-based primary care professionals are, despite COVID and a profound workforce shortage. And that commitment is so evident, even in a situation like this one, where these experts are just so enthusiastic about sharing their expertise so that more patients can get this kind of care. So Dr. Paul Chang, Dr. Ina Lee, Dr. Tom Cornwell, Michael Kingan. Are we still on? Oh, yeah, there we are. Okay. So Michael Kingan, Brianna Plentsner, Amanda Tufano. And then finally, thank you to our learners. The work you are doing has never been more important. Thank you for investing in your professional development by spending these last two days with us. HCCI's mission is to expand patients' access to high-quality home-based primary care. And we know that at least 1.7 million patients in this country have no access to this kind of essential care in their homes. And HCCI is committed to growing and training the HBPC workforce through education, including workshops like this one, through our library of online courses, through our shadowing opportunities, through our HCC intelligence program, where we offer a hotline and bi-monthly webinars in an extensive repository of tools and tip sheets. And finally, HCCI is accomplishing our mission through consulting and customized education provided to practices and health systems across the country. So we encourage you to stay in contact with us if you want to be included in that directory so that you all can continue some networking. Please go ahead and fill that survey out to opt in. You should have received that in an email. But we also want you to check out our website, contact our hotline, subscribe to our newsletter, and let us continue to help you achieve your professional and practice goals. So again, on behalf of HCCI and our faculty, thank you for attending this virtual workshop. And we hope to see you again in the future so that we can continue to walk alongside you as you serve our nation's most vulnerable patients. Have a nice weekend. You have all earned it. Thank you. Thank you. Thank you all. Thanks. You guys are all amazing. Thank you. Bye-bye. Bye, everybody. Bye.

coding

billing

home-based primary care services

advanced care planning

transitional care management

prolonged services

documentation