Hi, everyone. Thank you for attending. We have a large number with us today, so we're just going to give it a few seconds here so everybody can get into the webinar. Don't want anybody to have to miss any great information today. All right. We're still just waiting a little bit longer, guys. We had over 100 people today, so we just want to make sure as you guys are trickling in that we make sure everybody's included here. All right. Looks like we've got a quorum here, so thank you for joining us today on what is our last HCC Intelligence webinar for the year, but what I believe is probably one of the most important. So today we are going to talk about 2022 coding and policy impacts, what home-based providers and practices need to know. And we know that's a lot, so we're going to help you today synthesize some of that. Next slide. Today we are joined by two really great presenters, Dr. Paul Chang, Medical Director at Northwestern Medicine and Home Care Physicians, as well as our Senior Medical and Practice Advisor here at Home Centered Care Institute. Along with Dr. Chang will be Brianna Plensner, who is our Senior Consultant and Manager of Practice Development here at Home Centered Care Institute. Again, I know you guys will find this extremely valuable, and I'm excited to share with you their knowledge today. And with that, I will pass it over to Dr. Chang. Dana, thank you so much, and thank you everybody for joining us this afternoon. So our session today, our objectives are, we're going to go over some of the significant coding, reimbursement, and policy changes for 2022. And we're going to talk about how we can best respond to these changes. We're going to discuss some of the payment impacts to home and domiciliary E&M coding. I'm going to highlight some changes to care management services, telehealth, as well as remote virtual care. Next slide, please. Now before we get into this, I just want to say a big thank you to all of you who are doing this. You know, the year is coming to an end, and I hope it's been a rewarding year, a fruitful year for all of you as we are out there taking care of these sick and complex patients who are really in need of our services. And as we look to a year of 2022, Brianna, there were some concerns, many of us who have been following the news, there were some concerns about a potential reimbursement cut in terms of the home and domiciliary CPT code. As much as 3 to 4% going into 2022. But then something happened this past week, this past Friday. Can you tell us a little bit about what happened, what was kind of concerning, and this conversion factor, and what transpired this past Friday? Next slide, please. Yeah, thank you, Paul, and thank you everyone for joining us this afternoon. I was a lot more optimistic after Friday of last week going into this webinar because I have better news than I originally expected to be able to present. So, there is legislative and regulatory requirements that CMS has to follow. So, we talked about the kind of 2% sequester that has to balance the physician fee schedule and sometimes causes payment impacts. So when we first received the final rule, the conversion factor did go down for calendar year 2022, as well as we had some across the board, it was not like home providers were being disadvantaged. All physicians and clinicians were going to be impacted in various different specialties in certain ways, based on this conversion factor, due to the balanced budget act and other legislative policies that CMS is required by law to follow so it's not that they were just trying to disadvantage us. But the good news is there was legislation just passed on Friday. It was again provider relief legislation called the Protecting Medicare and American Farmers from Sequester Cuts Act. And so what that did. These are all the key impacts, but instead of that, you know original it was going to be 9% across the board but they kind of took things and they said okay, if we have to do these payment cuts let's at least make it manageable and let's not penalize our patients who are supporting patients during coven. So what they were able to do is delay, the 2%. So the first, you know, three months of 2022, we should not see any change from the 2021 impacts. Then, in the next three months so starting in January, so January through March, should be the same as 2021, then April through June, we can expect on average about a 1% pay cut, and then July through December that other 1% will go into effect. But the real kind of win from this too is the delay of PAYGO. PAYGO was going to be up to 9% payment cuts across the board so that what they've done is they've at least delayed that for a whole other calendar year, giving CMS and the other legislative committees time to figure out how they can address payments. So what I've done for you here, and keep in mind these are, these are somewhat estimates but in the right hand column, this is what we were going to look at, we were going to see like Dr. Chang mentioned that three to 4% pay cut for our home and domiciliary services. So that's where I have that kind of grayed out. What I have included for you is the 2021 national CMS national fee schedule payments. I'm going to show you how to check based on your locality, because again based on your geographic region these numbers may vary. So just a little disclaimer all these prices that I'm going to show you throughout these, this presentation, a lot of them are estimates based on the conversion factor so we'll have to wait for the fee schedule to get updated there may be some changes. You know you can and I'm going to show you how to how to verify in your locality but here are the home services so if you're seeing patients in a private residence, that's their home, independent living, that doesn't have you know that's not considered an independent living or group setting that is a domiciliary setting these are kind of what you should expect. And then here we have the domiciliary payments, again we're going to maintain those 2021 rates for the first three calendar months, and then we can expect a 1% for three month potential impact and then another 1% for the remainder of 2022 but the good news is at least that's all we'll see I know it's not all good news, but we really did have a big win this last week with the legislation that was passed to prevent what could have been a lot harder pill to swallow with these with the payment cuts for the for 2022 and 2023. So, I often get asked to how you can look up your fee schedule like I said I like to use. If you just search in any web browser the CMS position fee schedule calculator tool. The problem with that is it generally takes several months to update. So what I've included here is the link to if you're not sure who your Mac is that's a Medicare administrative contractor, they are who governs Medicare policies and payments and claims for your local area, so you can search by state. And I've just pulled one example, national government services is the Mac for Illinois, and many other states as well. So depending on your state, you went to your Mac every single Mac has a fee schedule look up tool you can download a spreadsheet of the codes, you know they do have the 2022 schedule for NGS already up again that may be updated a little bit as they catch up with the legislation. But you can easily search for this in your area if you want to verify fee schedule prices to kind of see what this looks like. But again, you're just going to need to give all the Macs a little bit of time to catch up and finalize this fee schedules to make sure those payment rates are correct so trying to give you the most accurate information we can with with kind of the fast changing payment environment here. Thanks Brianna and throughout this presentation we hope you know when we hear about pay cut or pay reduction, you know we get a little disappointed, but we hope to give you some encouragement, we're going to talk about other ways to perhaps increase your revenue through through other services that you provide. So stick with us. There's, I think, more good news to come. Some of our practices, like for my practice, we only go to homes but there are other practices that not only take care of patients in the homes, but they also take care of patients at a skilled nursing facility. And occasionally, the provider team. They go into a skilled nursing facility with a provider physician provider and a mid level provider. And sometimes they, they see the patient and they and they take care of their needs as a team. So we're going to do kind of a split share visit on a patient. Can you tell us a little bit about the most recent CMS changes or definition regarding how we should document code with a split share visit between a physician provider and a mid level provider. So I'm going to move to the next slide which provides you with a definition for split insurance services I do want to be clear like Paul said this does not apply to the home setting, it does not apply to the assisted living. This policy would only apply to providers and practices that are seeing patients in a skilled nursing facility, or an inpatient setting. And we wanted to highlight at least all of the changes we do know a good chunk of practices that have home based So I thought it was worth at least mentioning and making sure you're aware of. But again, just to be clear, you know in the home in the assisted living setting whoever is seeing the patient face to face bills for it, but the split and shared policy is, if you are in a facility setting, and the E&M service so your, your CPT visit code for that day is provided both like Paul said by a physician and a non physician practitioner is the term that Medicare uses but we know that means our advanced practice providers, whether that be a nurse practitioner or a non physician assistant who are under the same group, and can do so by, you know, state laws and regulations. Let's say they're co rounding so both the physician and the nurse practitioner may see the patient or provide parts of the service. What Medicare's policy is that they clarified, is that that visit can be billed under whichever clinician the patient is a substantive portion of the visit and they've gone on to define that they are requiring a modifier it was, it was a little unclear and the final rule the only modifier they referenced was modifier 52. So we'll have to confirm that my policy goes forward with that. But what they're saying is for calendar year 2022, if you have a team based care model where both providers are seeing or in part, contributing to the face to face service that is provided to the patient. And this could be for new patients or established patients are in the nursing home those initial or subsequent encounters, whoever provide the bulk of the visit bills for it so could potentially be billed under the physician which we know is important because they get paid 100% of the fee schedule, where advanced practice providers are paid 85% of that fee schedule. And I know all of this language is from CMS they did you know you do need to make sure your documentation supports what you're saying you know they don't consider just poking your head in or not that really involved perspective from the physician to constitute under the physician. But I wanted to highlight it. The other interesting thing is they said in 2022 will define the substantial person of the visit as either the history exam or medical decision making, or more than half the total time of the service but we know that not all services are built on time, but they are going to change that in 2023 they want to give a transition years the rationale they gave. What I'm referring to is I think we may see coding and documentation guideline changes for the skilled nursing facility like we saw for the office because they're saying come 2023 that substantial parts of the visit has to be total time and you can't use these other things but for the immediate calendar year. If you are seeing patients in a nursing home and you are doing team based care, you may want to check out the split and shared policy so that you can understand who can bill for services, So again for 2022 it could be any of the elements history exam or MDM in 2023 it's going to have to be total time. I find it like the CMS even have a sense of humor when they put the poke their heads in the room, kind of comment I said you know I can, I got a little chuckle out of that. Not so stoic after all over there at CMS. So Brianna would you say it's a good idea. If we're doing the split share visit to start. Even now documenting visit with a timestamp. What do you think, I agree, I think, you know, the benefit. Of the time based services. You know, maybe, you know, it's never bad to have a timestamp you can also have a lot of times the MR has timestamps that you could include, or you could look at when the provider started and close the note without even having a timestamp because if I see that time statement in the bottom of your note that tells me that you're wanting to build on time so we definitely don't want to include that every time when we're trying to build on documentation and complexity rather than time. But if you are building the end service on time time has to be there. I would say I think it's a good idea for us to start being aware and tracking time, even if that's not a time statement your EMR usually has the capability to look at in and out times from the visit, or when the patient was quote unquote checked in and out so you could look at some timelines that way as well. Thank you for that. Next, yeah. As you know, doing what we do we do a lot of not only face to face visit with our patients were at a facility. When we monitor their health, either by phone or electronically. So there are some opportunities for us to get some reimbursement for the care management and the care monitoring that we are providing for our patients. Next slide please. Yeah. Yeah, so CCM has been the reimbursement for CCM has been increasing over the last year or two, and I was going to ask Brianna you know is that trend continuing. It certainly is so chronic care management again, these next few services that we're going to speak about our fee for service billing opportunities so if you're in a value based payment arrangement or participating in one of the alternative payment models, you may not be quote unquote billing for these separately because they may be bundled into your per member per month payment that you're receiving. So what chronic care management is is a framework that CMS has created for patients that have multiple chronic conditions who have two or more chronic conditions which we know are all of our patients for for home based care that would benefit from close management and coordination from a primary and advanced primary care practice and so you have to meet certain requirements, such as using a certified electronic health record, creating a monitoring and, you know, maintaining a comprehensive electronic for the patient, and then be based on the code, the billing provider which could be a physician or nurse practitioner physician assistant as well as their clinical staff counts their time, you know, phone call interactions coordination with other community coordination with home health and hospice. You know all of those things that we know are critically important that go on outside of the visit CCM is offered as a way to be paid for those services when you are the primary provider only one provider can enroll and bill for CCM for patient. So when you are the primary provider and you're responsible for managing that patient's care plan, you can be reimbursed for not only your time, but also your clinical staffs time so we have seen them they. This is the biggest increase in 2022 that we've seen, and they've also given us a new CCM CPT code so just briefly, the 99490 that's your traditional CCM. It's commonly referred to so that's when you're counting both the billing provider and the clinical staffs time, and you're billing at you have to meet at least 20 minutes per calendar month, or if you spend 40 or 60 minutes per calendar month and that's when you're using that second code, the 99439. You can't bill any of these types of CCM you can't build all of them so that would be option a right traditional CCM. Your second option for billing CCM services is the 99491 which I call provider CCM, that's when, especially if you're a smaller practice, and the billing provider is the one spending the bulk of the time with the patient so they are spending 60 minutes per calendar month of their, you know, qualified healthcare billing provider time. That's when you could build 99491 and that's why it pays a little bit more. And then the new code that CMS gave us starting next year is the 99437 when a total of 60 minutes of qualified billing provider time is spent per calendar month, you would build both of those codes. Again, the complex CCM codes are not new but we did see an RV you increase for these services. Again, these prices were estimates based off the conversion factor. So again, we may know there may be some, you know, some variants amongst regionals, but this is just showing you we're seeing a big RV you increase so regardless this means you're going to be paid more for your chronic care management services 2022. And this can be a way to offset that 1% or that 2% payment decrease that we're seeing and getting paid for the work you're already doing, you know, don't let this shy you away this isn't more work or more documentation. This is just creating a workflow that allows you to be paid for the things you're already doing for these complex patients. I have in the chat box. Do you want to address it now, we can address the question now. Sure, go ahead. Yeah, I think the challenge here is they're muted Paul but then perhaps then maybe we can save some of the question Oh that's if you can perhaps put your question in, into the, into the chat and we'll try to get to the questions later on this this afternoon, so thank you for that. So again, as Brianna said, to two things to remember, this could be an offset to the reduction in the reimbursement that we talked about early on in the session here. Again, this is not doing more work, it is not doing more work. We're not asking you to do more stuff. This is getting paid for the stuff that we are already doing. So keep those two points in mind. Rihanna, what happens if I'm a clinician and I'm not really managing a multi-complex patient? For example, if I'm a palliative care provider going into a patient and I'm managing one particular chronic illness, is there an opportunity for me in getting some reimbursement? There is. So principal care management is another care management service where you're collecting your time spent managing patients' disease. In this case, a single high-risk disease throughout a calendar month. So I like principal care management for palliative care providers, community palliative care providers. This can be a great option where maybe you're not the primary care provider for the patient, but you do have a role in managing it. The difference with PCM is like with chronic care management where you have to be managing the longitudinal care of those multiple chronic conditions. Principal care management is for a single high-risk disease that puts the patient at risk of hospitalization, which can be many of those times that you become involved. Again, only one provider can enroll and bill for PCM management. The requirements are very similar to CCM where you have to be using that certified electronic health record. You do have to create an electronic comprehensive care plan, although there is no specified requirements as in detail as the CCM care plan. And you do have to be counting your times throughout the calendar month, have a way for 24-7 access, have a way for electronic communication. So again, make sure you do your research before you implement these new services. PCM existed before, but they were G codes. So what Medicare likes to do is create temporary G codes and then eventually adapt them into CPT codes. So they changed these where you see it replaces the G code if you knew about this before. And then they did also create a new code, again, when it's that provider time versus clinical staff and provider time. So that's the big difference between these services. You need to say, okay, if I'm a small practice and I know it's mostly my time, probably makes sense to do the provider PCM or CCM time because I'm the one that's spending the time and the effort. If I know I have the support of my clinical team, that could be a way to hire an RN or kind of get paid for that clinical staff time that's helping manage your patients. And we are going to have time for Q&A at the end of this today. So I apologize. I just said I wasn't able to call on you when you raised your hand, but please continue to put thoughts in the chats and we'll get to as many questions as we can. Well, thank you for that. You know, it's been what, it's been over two years since COVID. And I can remember even for my practice, when we talk about, you know, telehealth is two years ago, it seemed like, oh, overwhelming, you know, how do I do this? And, you know, what technology pieces do I need? But for many of us after COVID and living with telemedicine and so on, I think it's become second nature to many of us. Just this past week, you know, I'm thinking, oh, well, you know, we're getting over COVID and hooray. But at a facility that we go to, there's been an outbreak of COVID cases. So we're back to doing some telehealth with those residents there. Any changes in the telehealth policy going into the new year, Brianna? We do. So we know that right now, you know, CMS, I do have to commend them, was very quick to act to change their policies in order to allow telehealth reimbursement for primary care services, as well as many other services. But all of those flexibilities, so what I'm referring to is the 1135 telehealth waivers that allow the home to be what Medicare calls an originating site for a telehealth service. So we know right now, if we do a video visit, and we have two-way audio and video, we fill our same CPT code, so your home code or your domiciliary code, and you use that modifier 95, and you get paid pretty comparable to that in-person visit. All of that is tied to the public health emergency declaration. The public health emergency has to be formally extended every 90 days. That's governed by the Health and Human Services Secretary. Right now, the public health emergency that's currently in effect will go through January 16, 2022. As Paul said, we know that the pandemic has continued to present challenges, so that very well could be continued to be extended. So moral of the story is, as long as we're in a PHE, you can continue to bill for your video visits, bill for those telephone, E&M call, you know, services for those audio-only interactions. But the problem is, we would need acts of Congress to change things permanently and open up telehealth access. So what CMS did is, because of the Support Act and the Consolidation Appropriate Act, I may be butchering that name, but because of legislation we had last year as part of the CARES Act, they did say that the home can be an approved originating site, and you can bill for Medicare telehealth services. Regardless, if it's for mental health. So the language that CMS has given us is, if it's for the purpose of diagnosis, evaluation, and treatment of a mental health condition. After the PHE, only for mental health will all of the access we have now continue. I was encouraged to see they were even thinking ahead about audio-only coverage. So again, they were saying, you know, okay, well, we would want an in-person service within six months before the telehealth services build. But also, you know, we know that not all patients can use video. So they said as long as the practice has the capability to do video. But for whatever reason, the patient may not be capable or does not consent to using video, and you want to do that audio-only telehealth service. Again, for mental health, that will be okay after the public health emergency. For our normal home-based primary care services, unfortunately, right now, you know, that's tied to the public health emergency. When it ends, we will no longer be able to continue to bill for those video visits. And the telephone E&M services for those audio-only is temporary. CMS did clarify they will stop paying for those when the public health emergency ends. Again, outside of mental health, that's the access that we're going to continue to have moving forward. But there are things like remote patient monitoring and communication technology-based services, those G codes for virtual check-ins, none of those are considered Medicare telehealth services. So there are some options that you can look into if telehealth is embedded in your model to continue to get paid for it, as well as the opportunities, like we talked about with chronic care management for counting your telephone time with patients. So again, just pay attention to the public health emergency, continue billing telehealth into January, at least until the 16th, but then we'll have to see if it gets extended or not. Otherwise, we will not be able to continue to bill for telehealth as we are and as we have been during the pandemic. Well, thank you, Brianna. I think many of us have heard about, and you brought up remote patient monitoring or RPM. I think there's a new kid on the block. It's called RTM. And can you tell us a little bit about that? And what are some of the opportunities for us household providers? There is. So look, because we love acronyms and they all have to be very similar, I'm not going to be spending too much time on this because I really don't actually think it's super relevant. I like the remote patient monitoring codes better. I know home-based providers that are using these. The reason CMS created a new category called remote therapeutic monitoring or known as RTM is really for other qualified healthcare professionals. They specifically said in the final rule that they think the primary billers of RTM services will be psychiatrists, non-physicians, and then other qualified providers like therapists, physical therapists and things who can't bill RPM because they don't have E&M within their scope of practice. The other big difference with RPM versus RTM is this is monitoring kind of change, right? Medication adherence or response to therapy, whereas remote patient monitoring, the patient has to have a medical device that's automatically and digitally transmitting physiological data to the practice. So that might be blood pressure, that might be glucose. This RTM service, they do have to still be using some sort of device that meets the FDA's definition of a medical device, but it could be patient reported. So again, these are probably going to be more used for therapy and other services. These are the codes for kind of the device and the initial education and supply. And then this is the code for kind of that ongoing management of the conditions. But maybe someone from the HCCI team can throw the link in the chat for HCCI's remote patient monitoring, the RPM resource. If you haven't heard of that, again, just thinking of ways that we can create sustainability for the work that we're doing. I think remote patient monitoring is better aligned for home-based primary care and home-based palliative care than RTM is, but we didn't want to not give you the information as you may be hearing about these codes because they are brand new for 2022. Next slide, please. And then again, this is just for reference. Some of these slides, I just wanted you to all have the information, but we can go ahead and move on to immunizations. Yeah, immunization. So many of us, for our practice, we administer vaccines at home. And I think even giving vaccination, there's a little bit of good news in terms of additional reimbursement. Next slide, please. Brianna, can you help us with these vaccinations? There is. So I think we've known for a long time that trying to be paid for something as simple as flu shots can present challenges, especially for smaller practices. So I think, again, trying to look at some of the silver linings of the pandemic. CMS recognized that they were underpaying for vaccine administration. So this is about a $14 increase. They're going to pay $30 per dose for flu, pneumococcal, or hepatitis B. And then they're going to maintain paying a little bit more for COVID-19 vaccines. We know those booster vaccination efforts are still underway. So they will maintain the $40 payment. When you're billing for immunizations, you need to bill for the actual injection itself, as well as the administration code. And then we'll go into the possible additional code for COVID-19 vaccinations done in the home. But this is good news. This is about a $14 bump in pay for giving immunizations to your patients. This is that other code I was referencing. This is kind of those things where it's like they're trying to do the right thing, but we're kind of stuck with that barrier, right? So there is an additional code. In addition to billing for the COVID-19 vaccine itself, which shows different codes, if it's first, second, or booster shots, then you also bill for the immunization. CMS did create a new HCPC code, MO201, if it's being given in the home. But the caveat to that is this can only be billed if it's the only service for that day. So if you're doing an E&M visit, you're seeing your patient as usual at home, and you also give them a COVID-19 vaccine, you can't bill for this third code. You can still bill for the COVID immunization and administration. This was trying to give people additional payment to recognize the additional time expense of going to the home. But unfortunately, there is a caveat in the regulations that you cannot bill for this with an E&M service or with any other service. Again, it doesn't mean you can't bill for it at all. We still are billing for the immunization and the administration itself. But this additional $35 payment is really only done. I know some practices that were trying to do a workaround where they were using nurses to be in the home, and then the provider was connected to video via telehealth because that meets direct supervision requirements right now. The provider can directly supervise and bill for it if they're connected via two-way audio and video. But again, it is a little bit of a barrier. So I just want to make sure if anyone's not clear on how to bill for COVID-19 vaccinations, we do have an HCCI blog post. You'll have access to these slides in your HCCI Learning Hub following the webinar. And then you'll be able to just click this link or go to our HCCI website under blog and check out the COVID-19 vaccination article, as well as I've given you a link to the CMS website. It has a grid with every code. Was it Moderna or was it Pfizer? How you get paid for these things, in addition to just confirming that they are going to continue to pay as long as the, through the calendar year that the public health emergency ends, they'll also continue to pay for antibiotic products if any of your practices are administering those at home. Yeah, Brianna, there's a question in the chat box. Perhaps we can address it quickly here. The changes in vaccine reimbursement, does it apply now or January 1st of 2022? Great question. So yeah, all of these will be January 1st of 2022. So everything that I'm going over is the Medicare physician fee schedule final rule. So we typically always get the final rule in November that tells us how we're going to get paid for the following year. So great question. Unfortunately the COVID-19 vaccine, they're already paying that $40. So that's the only exception. But if you're talking about the flu vaccine or those other vaccinations, that $30 rate will only take effect in 2022. Thank you for that. Next slide please. Now some practices are fee-for-service. Some are fully into value-based and we see a wide variety, whether you are completely at risk for your patient or you're kind of getting into an APM through an ACO or through an ACO's MSSP program. And for 2022, there are some changes in the Medicare Shared Savings Program as well as the MIPS performance category weights. Is that right, Brianna, if you can take us through some of the changes for next year? Yeah, so the Medicare Shared Savings Program are sometimes referred to the Quality Payment Program. We used to have MACRA and that went to MIPS. This is where you're reporting on clinical quality metrics and potentially receiving quality bonuses. Or maybe you're participating in an ACO. That's the Medicare Shared Savings Program where the ACO has 5,000 lives and they're being paid based on a population's performance. I tried to summarize the key impacts here in case we do have ACO-related practices. The good news is they're trying to streamline the burden. They're trying to reduce paperwork. They're giving us a longer transition period to be using reporting through electronic data registry and things like that. I often get questions. These are just the category weights. As you know, you pick 10 metrics and then your overall MIPS score is weighted on these different categories. That's what it'll look like in 2022. Again, if you're reporting clinical quality data to MIPS, the comment that I wanted to make is I often get questions on when do I have to or how do I know if I'm getting penalized if I'm not doing this? In order to be required to participate in MIPS, you have to bill for more than $90,000 of Medicare Part B services and provide Part B Medicare services to more than 200 patients and provide covered professional services to those 200 patients. If you're a smaller practice, you may not be technically, quote, unquote, required to participate in MIPS, but I would encourage everyone. This is the slide I was looking for because it has the tool. You can click this tool to check your participation status just by putting your NPI, and it'll tell you if you meet that volume threshold or not. As we think about transitioning away from fee-for-service to value-based payment arrangements, if you're trying to prepare yourself, I think thinking about reporting on clinical quality metrics, seeing how you would do in MIPS, or at least even just picking three metrics of your own to start reporting on and using that data to make guided decisions is a great way to do that. The Quality Payment Program also has free technical assistance for small or rural and underserved. If you're in a rural or underserved practice area, they will help you with MIPS. Check out their website. It's the qppresourcecenter.org, and then this specific link is how you can tell if you're what's called a MIPS-eligible clinician. I've highlighted just a few of the new clinical quality metrics included that I thought were relevant. The Home-Based Primary Care and Palliative Care Learning Network highly encourages home-based primary care practices to focus on functional assessments or cognitive assessments. Those are the only two that are endorsed by the National Quality Forum that they feel that work was championed by Dr. Bruce Laff and Dr. Christine Ritchie, who are really leaders in this field and are trying to think about what is meaningful quality, reporting meaningful quality metrics for a home-based complex population. Check out their website if you're not familiar with it, but if MIPS is Greek to you right now where you're like, oh, I've just been kicking that can down the road and I'm not really thinking about it, this may be a way to optimize your practice to prepare for value. Next slide, please. Well, there's one more. Yeah, so just, again, this isn't coming until 2023. This is just the MIPS framework is changing a little bit to what they called the MIPS value pathways or the MVPs, and these are going to be tied more to a population. So it's just, again, this was supposed to happen this year. They delayed it to 2023, and these are what the seven MVPs are, and there's a lot of information, like I mentioned, on that QPP Resource Center. If you're not sure what this means for you, I would encourage you to check that out. Thanks, Brianna. As if we don't have, we don't already have enough codes, there are more codes for 2022. We've got COVID and then we've got post-COVID, you know, that people talk about the long haulers and so on, and there are codes for that. And I think there's more and more recognition about social determinants of health and being able to document and code for those. Can you just give us maybe some highlights of important ICD-10 codes for 2022? Yeah, so everything we've talked about is like CPT or procedure coding, right, for the actual service that you provide. ICD-10 diagnosis codes was not technically included in the final rule, but they do get updated every October, and we do have some new diagnosis codes that I wanted to highlight. I'll be brief so that we have time for questions, but there is a new ICD-10 diagnosis code, and again, this is live right now because these changes happened in October of this year, for a post-COVID-19 condition. So if you're seeing a patient that had a positive COVID diagnosis but that infection has now resolved and you feel that their signs and symptoms are due to, in part, kind of a late effect of COVID-19, CMS is looking for a way to track that, so they've created a diagnosis code for it. Again, if you have a patient that is positive for COVID-19 for a second time, you know, you would still need to use the active COVID-19 diagnosis first, but I wanted to highlight that there is a post-COVID-19 diagnosis code. These are some other new ones. Low back pain, we got more specified codes. Also, you know, given how many more immunizations as we talked about, they created a code for safety counseling for vaccine product information, and then if your patients have diabetes, again, codes and codes and codes. You really have to use a code to identify the type of diabetes, and then if they're on long-term insulin or other drugs, there are other things to report on that as well. Not mentioned on the slide, but there are more specified codes just for cough as well. But what I really wanted to highlight is kind of the opportunity from, again, as we think about moving towards value-based care and paying more attention to quality and wanting to understand the non-medical needs that our patients have. We've had ICD-10 codes for social determinants of health for some time. We've gotten new codes, which I'll show you on the next slide, but I'm starting to see a huge interest from groups that are trying to encourage their providers and their practices to start using more ICD-10 diagnosis codes supplementing their chronic condition. So when there's that other social or non-medical factor that's impacting their medical care and impacting their overall wellbeing, you might be able to report things like this, homelessness, food insecurity, housing instability, all of these things that impact health and impact healthcare. The most common way to kind of track that from a quality perspective is running reports on diagnosis codes and then tracking outcomes and maybe doing a QI project. So I just wanted to highlight that these are available. The two big initiatives I'm aware of are something called the Gravity Project and then the PREPARE toolkit, P-R-E-P-A-R-E, that's talking about monitoring social determinants of health data and evaluating it. So if this interests you, check that out. And if you're curious what the other new ICD-10 codes are, I've included a link for you as well. Thank you for that. Next slide, please. Just this is our final segment. And for the sake of time, if we could just quickly cover some of the other policy impacts related to physician assistant, e-prescribing, and medical nutrition therapy. Yeah, so this was a really exciting, again, we've continued to see CMS recognize the need for increased scope of practice for clinicians other than physicians. Physician assistants are governed differently than nurse practitioners, and they had to assign their billing rights to an employer. As of January 1, 2022, physician assistants can be paid directly for Medicare services. That was a change. So again, this is just empowering our workforce, empowering these other providers that are going into the home, which we see as a really good thing. These last two slides I really just put in here, I think most people are using electronic prescribing now, but that is something that's going to be mandated for our opioids. You have to, you know, at least 70% or more. Again, there are some exceptions if you're caring for patients in long-term care facility or if you're a very low volume provider. I've put what the electronic prescribing requirements are, but if you're not e-prescribing for these, there are going to be compliance penalties that, you know, for non-long-term care providers start in 2023 and for long-term care providers will start in 2025. So take a look at this if you're not familiar with it and just make sure that you're trying to electronically prescribe as much as possible. And then finally, medical nutrition therapy services, these are billed by registered dietitians. Here's the definition. They used to be paid a lesser amount of the fee schedule, that changed. Again, these are referred to the CPT and the diagnosis codes. I only know one practice, but it is a home-based primary care practice that actually employs registered dietitians on our team. It has to be tied to diabetes or renal disease. Those are the only two diagnoses that Medicare will cover the service for, but there was a change this year that was pretty positive. So we certainly wanted to address that. Thank you. Next slide, please. I think, Paul, you know, I'm up to you, but I think we take some questions. Yeah, I think it's a great idea. This is just a summary slide in terms of, you know, we started with a little bit of bad news, if you will, regarding the pay cuts, but I just want you to, you know, take maybe a mental picture of this in terms of other opportunity for you to gain some reimbursement, again, for the work that you are already doing. Okay, I'll just end my comments there. I know there are a lot of questions. Dana, can you take us through some of the questions? Sure, sure will. Can you kind of spin us through to the intelligence slide? That might be helpful. So thank you all. Bill, thank you for Dr. Chang. Brianna, as always, great information. We wish we had a longer time because there's so much more to go over, but as a reminder, we will be putting out on our HCC Intelligence webpage, this deck, a recording of this call, and supplemental information or handout. If we do not get to your question right now, do not worry. You can email on your screen, help at hccinstitute.org. That is our hotline, and we will reply to any and all questions, and that's not just about this email. That's about any questions you have and any day of the week. So I'm gonna get right into them. Any suggestions regarding format for documenting or calculating CCM time monthly? Does messaging back and forth with clinical staff at assisted living facilities count? Yeah, so great question. A lot of EMRs nowadays have time tracking modules. Anytime we can use technology to do, to track our minutes throughout the month, to use that electronic care plan, communicate with those patients on that patient portal, that's always going to be a win. If your EMR does not have that, there are even other technology vendors that you can contract with. I know some reasonable ones, even for small practices, but what CMS is looking for is you obtain verbal or written consent to enroll the patient in chronic care management services. You explain to them what that means for new patients that has to be done during a face-to-face visit. You get that consent, then you start tracking your time. So what I would need is the date of service and the minutes total spent. How much did you spend on each date of service throughout that calendar month? And a short description of what occurred. So yes, absolutely, communicating with those assisted living facilities would be an opportunity for chronic care management. It does not have to be all direct patient phone call or interaction, it's for all of their medical and care coordination needs. But I would need to know the date of service, the total minutes spent, and then a description of that effort and that time spent. I do know for those who are not using their EMR modules, you can sometimes pick certain encounter types and just keep one running encounter type or use tags. So get creative, work with your tech support because there are ways to kind of track. And then the nice thing is you can just run a report at the end of the month, determine how many total minutes were spent and then bill for it appropriately. But again, they're looking for a total time spent, what you did on each date of service and that electronic care plan and those other requirements that are part of chronic care management. Yeah, having a template and having automation, I think it's really helpful. Otherwise it's just a lot of typing and going back and forth on your phone. Like, who did I call? How much time did I spend on that? So that can be a little worrisome. Okay, next question. Can PCM be billed with MLP? MLP, I'm gonna need clarification on. Principal care management is pretty flexible. I'm usually pretty good with my acronyms, but I'm not sure what MLP service you're talking about. I'm so sorry. Okay, well, we'll get back. Hamani, we'll get back to you on that one. Next one is, you can bill audio-only televisits along with BHI, behavioral mental health purposes, once PHE is over, correct? So, okay, there's a lot of pieces to that question. So once the PHE is over, audio only goes away unless it's for mental health. So there is another care management service that I didn't focus on during this webinar called behavioral health integration. There is different codes. General behavioral health integration is when the primary care provider is managing the mental health condition and coordinating the care for that patient. So yes, that's like CCM, where you're counting your time throughout the calendar months. So technically, you could bill general behavioral health integration services. And because Medicare telehealth service access will be granted for the purposes of mental health conditions, if you had a video call or things like that for the patient, you could potentially bill for those services too. You just have to be careful of what Medicare calls double dipping, right? Like if you're counting your minutes on that audio call towards your care management for a general behavioral health integration services, that's already accounted for billable time. If you're doing a separate and distinct telehealth service, and then not related to that throughout the calendar month, you're counting your time for behavioral health integration services, then yes, you could potentially bill for both. You would just need to make sure your workflows are clear and concise, so you're not double counting time and effort. Okay, I'm gonna take us back to the original question. We have some clarity. Can PCM bill be billed by nurse practitioner? Oh, yeah. So PCM can be billed by the PCM, CCM, all of these care management services, physicians, nurse practitioners, physician assistants, certified nurse midwives, and certified nurse specialists. Those are all qualified billing providers that have E&M within their scope of practice. So they can bill for any care management service and any E&M face-to-face service. So that would apply to your nurse practitioners. Again, just make sure you're one billing provider. So that nurse practitioner would need to be kind of independently enrolling and managing that patient's time and not adding time through different providers on the team. Great. Do you have to have a certified EHR in order to bill for RPM? In addition, what about FDA approved devices? So RPM, that's an interesting question about the certified EHR. I don't know if that is necessarily, I would be surprised if it's not, but I'll have to double check on that. It does not have to be an FDA approved medical device, but it does have to meet the definition of a medical device, which if you look at our remote patient monitoring resource, I have that definition in there for you. But what RPM is, is it has to be a device that's automatically and digitally transmitting that data, whether it be blood press or glucose. You can't call a patient or have a patient call you and they're monitoring on an Apple device or their home blood pressure cuff and then just manually reporting those readings. That does have to be a technology vendor that is automatically sending you data on your patient. So my guess is, I'd be surprised if you're doing that with the EHR, unless you're just using a separate vendor, but I apologize that we'll have to double check on if that's a requirement, but it does not have to be FDA approved. It just has to meet the definition of a medical device. All right. Okay. Let's see here. Can you use HCPSCS code MO201 for patients in care homes or group homes? We're gonna test your acronyms today. Yes, that one was the additional diagnosis code for giving a COVID-19 vaccination done in the home. And yes, they were considering group homes and even assisted living facilities. There's just regulations on how many patients you're giving in one locations and how many times you drop that code. So look at the CMS fact sheet or the blog post, the HCCI blog post I referenced. I go over all of that in more detail and give you the link to the CMS fact sheet that you need, but it can be used for not just private homes as well as group homes. For time-based billing, what about when the provider opens and starts the note, history or care plan review prior to visit, closes it and reopens it when the face-to-face encounter begets? Okay. So for time-based billing in the home and the domiciliary setting, the office, I'm guessing this question may come from someone that provides multiple services in multiple settings, because it's different for the office where we can count that non-face-to-face time. You cannot. If I'm billing your E&M service, so if I'm billing a 99349 for that established patient house call, I can only count my total face-to-face time with that patient and caregiver. So it has to, not only am I billing just on time, it has to be dominated by counseling and coordination of care. I have to have that time statement that tells me I spent 60 minutes face-to-face with the patient, greater than 50% of it was dominated by counseling and coordination of care, and then describe the nature of the context of what counseling and what coordination of care went on. There is a CPT code. If I go back, oops, I went the wrong way. The 99358 for prolonged services non-face-to-face, that's directly related to a face-to-face encounter. So let's say you were reviewing medical records in advance, preparing for a new patient visit, I could potentially bill 99358 if that took me 31 minutes as the billing provider, and then bill your E&M service, whether it's billed on time or not, doesn't matter. But the non-face-to-face 99358 is 31 minutes before or after an E&M service that's directly related to it. Now that is bundled with chronic care management too. So again, just check out our resources where I go over that service in more detail. So yeah, again, the 99358, if you're doing a lot of chart review, I joke about the two-inch record that you get on your desk for your new patient visit, you're taking time to review all of that and putting into your EHR, that you can count as time. And I think Brianna also, if you are back in the office and you spent a lot of time talking, say with a power of attorney who lives out of state, going over a care plan and reviewing records and medical management, you can count that as a non-face-to-face time. Is that correct? That is correct, yeah. So the other use case is like they referenced in the CMS language patient and family care conferences, but let's say you have an extended phone call with a family member that wasn't present during the visit. Again, it's directly related to that face-to-face service and you're not billing for anything else that's bundled with it during the calendar month. Again, that's only non-face-to-face time directly related to a service though. So it can't just be, they called you, it turned into a really long conversation. This is a prolonged services, non-face-to-face, minimum of 31 minutes, all by the billing provider when it's directly related to an E&M service. All right, great. I'm gonna take one more question and then if you guys wanna stay on for an extra five minutes, I think we have a few that we can get to, but I wanna be respectful of people's time. Let's go with what is required in the CCM comprehensive care plan monthly? Yeah, so it's quite a lengthy requirement. We have a resource on that too. If you go to our HCC Intelligence Resource Center and look for our CCM care plan requirements handout, again, all of our HCC intelligence resources, those tools and tip sheets are free. You just have to log into the HCCI Learning Hub to access them. But problem list, treatment plans for each of the chronic conditions that you're monitoring, who else is involved in their care, it's a very extensive list. So check that out, make sure that you're, again, that's done once when you enroll the patient in CCM, you create that comprehensive care plan. You have to give them a copy of it electronically, preferably if they have access to a patient portal, that counts as you giving them a copy to it or another electronic means, or giving it to them afterwards if they're not active on the portal. But it is pretty extensive. After you create it the initial time, you just have to have a schedule for periodic review. So I would say at least once annually, because generally care plan changes are gonna be documented elsewhere within the EMR as they occur so frequently. Okay, great. Can you bill 99358 and CCM in the same month? No, you cannot, it is bundled. So that's another where you have to pick one or the other, or if you wanted to be really savvy, I might say, if I know I have a new patient visit where I'm spending a lot of prep time or follow-up time, maybe I don't bill chronic care management till that second month. So maybe I'm doing non face-to-face for that first month because it pays more, I think it's $113 on average. And then you still enroll your patient for chronic care management, but maybe I don't start billing for my time till the second month. Again, all billing software, your revenue cycle management software has what they call charge review rules and things that you can build in. So your clinicians don't have to worry, did I bill CCM, did I bill prolonged services? That should be something that can just be a backend billing process so that multiple claims are not billed within the same month. Great, I'm gonna go with one more. AMA and AAFP are touting the MCR pay cuts. They were reversed temporarily. If so, which ones? Yeah, so what they're talking about is that legislation that I talked about at the beginning of the year. The AMA was of course heavily involved in that advocacy. So originally this year across all the different specialties it was gonna be something like 9% total pay cuts. So they prevented pretty much all pay cuts. The Medicare sequester is required by law, right? For budget neutrality purposes, we have to implement that. So what they did is they did that phased approach. So they delayed pay go at least until 2023, they're given CMS and the legislators another whole year to figure out how to avoid the pay go cuts that were gonna be more substantial. And then as far as the 2%, we're still gonna see that throughout the whole calendar year in 2022, but it's gonna be phased and broken up more adequately across different E&M services. So that not one specialty is more disadvantaged than another. So that's where, if I went back to the beginning of the, I don't wanna give anyone whiplash, so I'm not gonna go back, but that's where you have that 1% cut after the first three months into calendar year 2022. And then we'll have another 1% cut through the last three months of 2022. That's the efforts that the EMA and many other advocacy organizations were a part of. Okay, great, thank you again for addressing all of those questions. And for the acronym quiz, I think you scored almost 100. You wanna take us down to the slide past intelligence. So thank you guys for joining today. I know there's a lot of information. You guys have tons of questions. I think we got to most, if not all, that were in the Q&A or chat box. If we did not, and you need to reach our experts, inclusive, those of you who are seeing here on the screen, send an email to help at hccinstitute.org. I'll also encourage you to keep an eye out for a new series on billing and coding that we will be doing in Q1 of next year. It's Maximizing Revenue and Value in 2022, Billing, Coding and Documentation in Home-Based Care. So it'll be a three-part series and we will start in February with Mastering E&M Coding and Documentation for Home and Domiciliary Settings. March, we're gonna take on Maximizing Revenue Beyond E&M Coding and Documentation. And then in April, which I am really looking forward to is Empowering Practices, helping you learn how to implement internal coding audits and quality improvement plans in your practice to help you. So we will be sending out more information on that as we move forward. We, again, appreciate you for joining us today. If you have any questions, don't hesitate to reach out and thank you all. Bye-bye. Thank you all so much for joining us today. Take care. Bye.

coding changes

reimbursement changes

policy changes

home-based providers

E&M coding

care management services

telehealth

ICD-10 diagnosis codes

chronic care management

comprehensive care plans