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HCCIntelligence™ Premier Webinar: Maximizing Reven ...
Webinar Recording- Maximizing Revenue
Webinar Recording- Maximizing Revenue
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All right, welcome, everybody, for joining us today for our HCC Intelligence Premier Webinar. This is the second of a three-part series. Today, we're going to be doing Maximizing Revenue Beyond E&M Coding and Documentation. My name is Dana Crosby. I'm the Senior Director of Engagement and Practice Development here at HCCI. I'll be the moderator for today's webinar. It will last an hour and a half today. The first 60 minutes will be the bulk of the presentation. The last 30 minutes that we will have is for Q&A. We will open up Q&A for it to be interactive. We encourage you guys, even now, to show your video. Feel free to unmute and engage with us during the presentation. If you are shy and you don't want to ask your question at the end, feel free to put it here in the chat box of the Q&A. I'll cue those up. I'll track those and cue those up when we get to that session. But we really would love for you guys to save it for the end and have a conversation with us and share it with everyone else. During the presentation, feel free to use the comments for any kind of shout-outs, additions that you'd like to add. And then, just as a reminder, and I'll remind you at the end, all of today's materials, the recording, the deck, and all the supplemental handouts will be in the HCCI Learning Hub in your account that you should have access to. We usually have those up within 24 hours, so you'll be able to see those tomorrow. So with that, I'm going to get started with today's webinar. Next, we're going to talk a little bit. I'm just going to get through some formalities here. None of the planners or faculty for this educational activity have relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients. The next formality is just to remind you guys that this is CME credit, that you can use that. You can also find that on the HCCI Learning Hub on those processes. And now that the formality is out, we're going to get to the fun part. So today, we have with us two nationally recognized experts in the field of home-based primary care. They are also colleagues of mine that I have learned a tremendous amount from, and I know you will too today. So joining us is Tammy Browning, President of Grace at Home, and she's also the Director of New Market Launch Strategy and Acquisitions of Village Medical at Home. Also joining is Brianna Plintzner. She is the Senior Consultant and Manager of Practice Development here at Home Center Care Institute. And I know that you guys again will have a very interactive and informative hour and a half. So with that, I am going to cue it over to Brianna to start the presentation, and I'll start monitoring the chat throughout. Thank you all for joining. Thank you, Dana, and thank you, everyone. Thanks for making the time out of your day to be with us today. We're excited to kick off our second webinar of the series and have some robust conversation at the end. So the first webinar, we focus on E&M, your bread and butter, how do you make the most for your visits and the things you do on the daily. Today, we're going to talk about other opportunities. I call them advanced coding opportunities, but how do you get paid for the other stuff, that non-face-to-face work, extended time? And then how often also do you think about team buy-in? How are you incentivizing your team to, you know, what could be perceived as extra documentation or extra work, but tie it back to the mission and the additional resources that enables you to go ahead and participate in? And then what implementation considerations do you need to consider? You know, some of these coding opportunities may seem complex, so we want you to leave here with a clear plan on implementation and other considerations for these kinds of services. So it's not going to be a formal poll. I'm going to turn it over to Tammy to frame up a little bit about her program and talk about grace at home, so you all understand the perspective that she's coming from when she shares. But we'd love to hear in the chat, who's a fee-for-service practice? Do you have any mix of both? If you're participating in any alternative payment models or any contracts with Medicare Advantage? I think it'd be helpful if you all don't mind sharing in the chat just what your current payment model arrangements and experience look like. And I'll turn it to Tammy. Hello, everyone. Nice to be here with you. I appreciate the opportunity to share my experiences. I started grace at home. I'm a physician assistant by training and started grace at home about 12 and a half years ago out of my living room and contracted with a supervising physician and hired an office staff person to come to my living room and work every day to help support me and the patients that I went out and marketed to and acquired and then provided care for. Those of you who've done this from grassroots startup probably can relate to those those stories in the early years. Over the course of those 12 years, we grew to service all of central Indiana. We're based out of Indianapolis, Indiana and grew to 14 providers with over 2,000 active patients and servicing about 20,000 patient visits a year. So substantial growth over that 12-year period, mostly fee-for-service. We started out as wholly fee-for-service and do certainly some pay-for-performance, pay-for-quality through some Medicare Advantage payment programs. In 2020, I joined or participated in an ACO. I joined in the year before but started participating in 2020 and 2021. So that was my first attempt into true value-based care. Didn't go real well. We performed well in the ACO but it was an MSSP and if you know anything about MSSP, you know that attribution happens from either voluntary alignment or is triggered by physician visits. Our practice, Grace at Home, is an APP model practice where physician assistants and nurse practitioners provide the bulk of the care directly to the patients and bill under their own NPIs and do that with a medical director who's a physician. So we started out with great attribution and that dwindled over the course of two years to where we ended up at the end of 2021 with four patients, four out of our 2,200 total patient lives. So we had applied to participate in a DCE for 2021 and unfortunately through no fault of our own that didn't come to fruition because of the MSSP didn't terminate us in proper timing for CMMI to accept us into the DCE. Lots of stories to tell there so we'll get into more of that as we go but Brianna or Dana, you want to read through some of the comments on our members and what they come from? Yeah, I'm just kind of scrolling through the chat. We do have someone here on the direct contracting demonstration. The majority else are fee-for-service or some fee-for-service and Medicare Advantage. So sounds like people have some similar experiences and again we encourage you feel free to use that chat to kind of communicate with each other and us throughout this presentation. But kind of as we think about optimizing revenue, especially with so many fee-for-service practices, we know that house calls provide tremendous value but we don't always feel like that when we just look at what we're getting paid. So we have to be really strategic in how we optimize our fee-for-service revenue to get paid for the work that you're doing taking care of really sick patients. So to kind of frame up this conversation, what do I mean by optimizing revenue? So to give you some food for thought here, when I say you invested the time, effort, and education to understand how to appropriately bill for services, that means that there should be formal coding and documentation education at onboarding and I would say at least once annually. And how are you investing in your team and really supporting that? And when you, you know, when you provide these services where you're spending 90 plus patients or you have a really difficult new patient, you understand how to get reimbursed for that time and what codes to use in those scenarios as they arise. You also need to optimize workflow. The last thing that we want to do is roll out opportunities that are overburdensome and templates that aren't optimized. We want to get paid for this work in the most seamless and efficient way possible. So that's what I mean by implementing workflows to utilize that kind of these kinds of opportunities. Not a lot of practices take the time to monitor their billing trends. It can really tell you a lot if you look at your own internal team. So what I mean by that is do you look at the billing patterns, you know, 99349 versus 350 against your own providers as well as national benchmarks. If you because if you have, you know, three or four of your providers that are mostly we know 99349, which is the level for established patient house call or level three, I'm sorry, is the most common. And one provider is really below that, then maybe they need some extra education or support to feel comfortable in coding at an accurate level of service when it's appropriate. It's not going to be the highest level of service every time. That's not what I'm trying to tell you. But looking at some billing patterns can really give you a lot of information. And then revenue cycle management. Many of you may use a third party billing and coding company, which is fine. There's good and there's bad ones. But do you have access to that information? I was looking for a little statistics before this webinar. And there was a 2017 article from Change Healthcare that said the average cost of one denied claim is $117 just for one denied claim. And, you know, if it's not resubmitted and appealed, did you get paid for that? So that adds up a lot. Maybe you have an internal billing support, which is great and can help you kind of work that but that's really a time consuming process. And if you are using an external company, how transparent are they being? Are you meeting with them monthly to look over month end reports? Does you have an EMR vendor that's doing the revenue cycle? How well is that working? And then we know, you know, we get a new fee schedule, final rule every year, a lot changes, there's new opportunities, you know, staying up to date and making sure that you know, we're going to talk about remote patient monitoring, that's fairly new. So making sure that you're kind of staying up to date. And then at the same time, like Tammy's talked about, you know, we hope that the future of healthcare is value based care, we hope that that makes this easier for us to get paid for high quality care, with less burden and less documentation and more flexibilities to provide care in different ways. So how do we start thinking about that now? And even if you're, you know, small, big, medium size, you know, what do you need to do now to prepare? Tammy, would you add anything before we move on? I would say personally, you know, when you start out, and it's just you, or it's you and one other provider, it's easy to train and retrain on billing and coding. But as you grow, certainly I found I like your your nod to revisiting it annually, I would say at least every six months, as you're growing, and you're adding new providers. And believe it or not, when when you're running the business, it's really easy to stay abreast and know what's going on. But your other providers don't have that same interest level in the billing and coding that you do. And they're going to be more interested in providing care to the patients. And so if you're not constantly re educating, personally, we would. So so that's a good thing to keep in mind. But oh, you got it. Thank you. You cut out a little there, Tammy, if you want to put that last reeducation point, maybe in the chat at some point as we go on. So this is a big screen, we're going to focus on the ones that are bolded is what we're going to talk about in detail today. So we're going to talk about chronic care management, transitional care management, RPM, and kind of compare CCM versus CPO. All of these other services on here are things that well align with home based primary care or home based care in general, you know, palliative care, you know, don't forget about you, either there's opportunities that our community palliative programs can take advantage of as well. But you do have a resource that describes all of these things in more detail. And Tammy, do you want to share which of these opportunities you're billing for in your practice? Yeah, so we are currently billing for home health certs and research, chronic care management, transitional care management, advanced care planning, remote patient monitoring, and occasionally we'll do some prolonged services, not as much in smoking cessation, of course. Great. My other piece of advice with this is when you're looking at coding and reimbursement opportunities, think about what you're already doing, what aligns with your care model, and there might be a payment opportunity that exists to kind of get paid for the work that you're already doing. So chronic care management's not new, it's been around since, well, I shouldn't say the long time, like 2017, well, 2015, 2017, but would love to hear in the chat if you're already billing for CCM, what do you like about it, any barriers? Again, we want your feedback, we want this to be interactive, so please feel free to share that in the chat. But I always like to start is because it is a time-based code, I'll hear it's like, oh yeah, I just have to spend 20 minutes and throw that in my EMR and I'm not. It does take a strategic workflow because there are a lot of requirements, including some interoperability, IT using that certified EMR, so it really is important to understand what you're getting in through, into, excuse me, and we're going to talk about that. So the bullets on the right-hand side of the screen, these are all your patients, but yes, they have to have two or more chronic conditions that place them at significant risk. That comprehensive care plan is a big one, that's not just what you document in your assessment and plan or an after visit summary, it needs to be a separate electronic care plan. You can play around with where that is in your EMR, but that needs to be provided to the patient and caregiver. The terminology that CMS uses is a schedule for periodic review, so you don't have to update it every visit, but I would say at least once annually, but making sure that you have that formal care plan documented and that you're documenting time throughout the calendar month. And we're going to talk about the difference of CM options and codes. So when I said it's more than just spending 20 minutes, this is what I mean. So at the start, when you're first enrolling patients in chronic care management for new patients or patients that you have not seen in the past 12 months, you must do so, you must gain their consent to enroll them in the program during a face-to-face visit. That's really easy to do if you just make it part of your initial visit workflow. I know a lot of programs that incorporate their CCM consents in their new patient forms, so they're getting that right off the start and then just documenting the conversation and talking to the patient about it during that first visit. It does not have to be written consent, it could be verbal or written, either is acceptable, but you do have to be using an EMR that meets the certified electronic health record capabilities. And a lot of that is because you'll see the enhanced communication opportunities, that could be a patient portal, that could be a secure email, different ways that you're communicating with patients, but some sort of electronic access. 24-7 access to care does not mean you're going to go make a house call at midnight or on the weekends, but it means they can reach you, they can get timely advice after hours, they have that relationship with whoever their primary care provider or clinician on the team is, that you have that formal care plan, and these other things you're doing. You're managing their transitions in a systematic way, and you're connecting them with home and community-based services. This is just some example language that you could use for a CCM consent, smart phrase, macro, or template. I get a lot of questions on how you document the consent, so I wanted to give you a resource with that. There is a clause in here, I should go back, about the copay. On average, patients maybe have an $8 copay from CCM services. If they have a secondary insurance after Medicare, that's typically picked up anyways. Again, part of this is going to be scripting. If you're introducing CCM services as this is a Medicare program that's encouraged for complex management of our patients, it's part of our care model. CMS even has, if you search CMS Connected Care, some patient and caregiver resources that are branded with CMS information on this program that you can use, or you could create your own. You do want some scripting. Again, this was just an example of how you might document that consent. The other resource, and you have this, as Dana mentioned, in the My Resources tab of the HCCI Learning Hub. On the right-hand side is what CMS recommends the elements of that CCM comprehensive care plan include. Anytime CMS recommends something, I recommend that you follow those elements. Again, this is where they said it's not all-inclusive, it could include more, but CMS has very specific recommendations on what needs to be in that care plan. Again, this needs to live and breathe in your EMR. The form that we gave you is a patient form, or is a form just for example purposes, but it does need to be an electronic care plan. The other important piece with the care plan is you must give a copy to the patient and caregiver. If they're not active on the patient portal, how are you delivering it to them, or how are you documenting that you delivered that care plan to them? Tammy, do you want to share anything about care plans in your practice? A lot of EHRs will have some care plan templating built in, or the capacity for you to construct that, as you will. We do not do it as part of our E&M visit. It is a completely separate document. It's important that it be a separate document. I've run into some practices that say, oh, well, we just spell out the care plan portions within our E&M visit. I don't know your thoughts on that, Brianna, but I don't think that's a good route to go. It needs to be a separate and distinct care plan. We've worked with our EHR vendor to make sure that that's built out separately. Excuse me. Yeah, no, I 100% agree. I hear that feedback, and I think it depends. I think about your training. Yes, technically, in your E&M visits, you're documenting an assessment and plan, and that is your care plan, but that's not what we're talking about when we talk about chronic care management. This is a comprehensive care plan for all health issues, hypertension, diabetes, COPD, what's the patient status, what's their treatment goals, an outline for each of those chronic conditions that you're managing. Because they say two or more chronic conditions, I would want to see at least three of them documented, but if you look at the CMS language, I do encourage it, since it's usually just done once at the start initially and then followed up on and changed periodically or annually, to just go ahead and document that comprehensive care plan for all of their chronic health conditions, especially if you're the primary care provider or at least the ones that you're managing. And the other thing I'd say, Brianna, is it's meant to be a living document. It's not meant to stay the same all the time. So don't feel like, well, we created the care plan. I can't revisit it for a year. That's absolutely not how it's intended to be. It's intended to be updated anytime there's appropriate change with the patient's plan of care, obviously. So I would say reference the care plan often and update it as you go, rather than just looking at it annually. And this is where your clinical staff, if you have team members, you know, can be super helpful. You know, that you as the qualifying billing provider can just review and sign off on it if you're utilizing other people on your team to do that. I know some practices that have a habit of, at least for new patients or after every patient, they forward their notes to care coordinators or some sort of clinical staff to not only follow up on clinical actions or call people to go over the visit and see how things went, but they also could be updating the care plan if you built that into their workflow, if you wanted to do it that way. So we have options. We have traditional CCM codes, we have provider CCM codes, and we have complex CCM codes. And you may or may not know that in this year, in 2022, CMS actually increased the reimbursement and the worker reviews for CCM services. So it pays even more now, and this really helps with practice sustainability and fee-for-service. Traditional CCM, that's when the minutes that you're tallying up or counting, if you will, throughout the month are both the clinical staff and the provider and the qualified billing provider. So that's traditional CCM. If you are a, you know, like Tammy, you started out like Tammy Browning and it's just you and you're running the show, and most of that time with your patients is you, then I would recommend provider CCM. And these are my kind of nicknames for it. But provider CCM is when it's 30 minutes, at least 30 minutes per calendar month, but it's all of the billing practitioner's time. You have to pick one or the other per patient per calendar month. You cannot bill a mix of either of these. So think about what's most appropriate for the patient. And then complex CCM, and we're gonna show you a reimbursement example later in the presentation, but just understand that complex CCM is a higher bar. You don't just bill this if you've met 60 minutes per month. Complex CCM requires that there's moderate to high medical decision-making demonstrated, which can only be done by a provider. So I would expect to see some substantial changes with that patient's health status. So a lot of provider involvement and not just clinical staff minutes. I was actually pulling up the CPT book before this because a lot of people don't realize the language for complex CCM. The patients have to have multiple illnesses, multiple medications, inability to perform ADLs, requirement of the need of a caregiver, and repeat admissions and ER visits. While that may sound like many of your patients, it is still important to understand that those are all requirements of complex CCM. So you can still bill up to 60 minutes of traditional CCM because we have these add-on codes. So your first 20 minutes would be 99490, and then you can use a maximum of two units. This code was new within the past two years. I think last year or the year before, I can't remember where they introduced it, but 99439. You could bill that twice, and you could still bill for your total 60 minutes per calendar month with traditional CCM rather than complex if you don't meet that higher bar. I wanted Tammy to share a little bit about this code. This is a G code. It could only be used for new patients that you're enrolling in CCM, and it's kind of a one-and-done per patient type service. But it's, again, just another reimbursement opportunity when you're having these conversations with patients about enrolling them in the program. Yeah, so the way we utilize this code and we bill it a fair amount is that we think about your new patients. You're going out and you're seeing your new patient visit, and it's a long visit anyway, but at the end of your visit, you're filling out information, you're talking to them about consenting them for CCM anyway. Take the time to actually establish the chronic care management plan, talk to them about how they could get it through the patient portal, and actually create that plan there. So we're billing a new patient E&M visit, a G0506, and an advanced care plan, because typically we're reviewed advanced care plan every time we see a new patient. It's a one-and-done G0506, but then we know that we have consented them to chronic care management. We've started their care plan, and your care plan doesn't have to be complete to bill the G0506. It just needs to be fairly comprehensive. You need to have the three chronic conditions listed and some interventions that you're going to be doing and some follow-up for the patient, their med list. You need to have a rough, but if you have a templated format for your care plan within your EHR, it's easy to pull some of that information in, but could you just saw them and took all of that information in their new patient intake? It's been a great workflow for us, and it really increases your fee for service reimbursement on that new patient. You're spending a considerable amount of time with the patient anyway, and what it really does for the patient is it establishes a really great rapport. You don't seem rushed. They appreciate that you took the time to really go through the care plan and their goals of care, to talk with their caregiver, who's typically more likely to be present on that first visit than some of the subsequent visits. So I encourage my providers just to take their time, do the work the right way the first time, get that care plan established, because then if those phone calls start trickling in or things start going on and you acquired 20 minutes within that first month, you can bill it. If you haven't consented them or at least established a care plan, then you're gonna have to go back and do that before you can bill for your 20 minutes of staff time. Yeah, absolutely. So you can't bill CCM until you've gained that consent and established that care plan, but Tammy's absolutely right. You can build a smart phrase or a macro or a template for a part of this of what's gonna be in the provider's note or at least have them start it in that separate care plan area. And then the clinical staff could finish it. It does have to be reviewed and signed by the billing practitioner. So don't forget about that step. But again, this service, there's no time requirement on this. If you notice nowhere on this slide, it says minutes, but you cannot use this. It will get kicked back since it says for new patients or not seen within the past 12 months. If you're enrolling an established patient, six months later or three months after you've seen them because you didn't do it during that initial visit. So like Tammy said, this is really intended to be used for new patients. So as we kind of think through CCM, if you don't already have a program, what do you implementation considerations, what are the different pieces? So how are you gonna use your clinical staff? What kind of clinical workflows are you gonna document? I'm a fan of process maps, make sure it's documented. I kind of laugh when I meet with teams, I'm like, oh yeah, we know how to do it. And then I meet with them and they're all doing it differently. And so, take the time to map it out. How should it look from enrollment to finish, all the way through the patient. And then how are you gonna track your time? And sometimes this is the thorn that pops up, but work with your EMRs, get creative. If they don't have a time tracker or a CCM module, which a lot of them do, ask and get creative. Do you have tagging or how could I track minutes? Try asking the question a little bit differently. I do know some providers that when they first started out, really just had one unique, they created a unique encounter type and they had all the different dates and minutes in one place throughout the month. That's not the most efficient, but it does work until your EMR gets the configurations that you need, but there's also a lot of vendors. So work with your EMR, I would say, chances are they probably have a way to do this for you already, but if not, get creative in how you're asking the question or look for other technology solutions. I do recommend a systemic way and use your technology to track the time. Don't overburden yourself. I've seen spreadsheets with CCM minutes, please don't do that. Use your technology if you can to track that time. And then again, the things you're gonna need templates for that care plan, the provider documenting the conversation with the patient during that initial visit, and then anything else that goes on, those clinical activities, just make sure your clinical staff understands how to document and capture their minutes, mostly so they're not missing time and your providers too. The great thing about CCM is once the patient's enrolled, every time they call you, all those lengthy conversations, the biggest question I hear is how do I get paid for this time? How do I get paid for talking to these patients and this family members? CCM is the easiest solution for that. And I think we've harped on the care plan enough, so I won't go on, but just make sure that your patients and caregivers have that. And then again, CCM is billed at the end of the month because you wanna make sure you've captured all of your billable minutes. You can bill, you have to spend at least 20 minutes. So 20 minutes is the minimum that you must meet to bill, but you can bill for up to 60 minutes per patient per calendar month and get paid for this non face-to-face care management time. And it does not all have to be live phone call time, any sort of clinical activity, as long as it's not administrative, just scheduling or things like that. Tammy, I don't know if you wanna talk about maybe some example of clinical activities in your practice. Yeah, absolutely. And a couple of points I'd like to make here, you said don't try to keep a spreadsheet and track your own time. That works when you're small and you've got 20 or 50 or however many patients and you can do that manually, but always be thinking about how am I gonna scale this? And if you start processes now that aren't scalable or sustainable as you grow, it's gonna cause so much pain and burden later down the road. So just really, I agree with her wholeheartedly and there's way too many options out there now for that time tracking. The billing process, I would say this, a couple of caveats. If you have, we see patients that are older and typically in end of life states, right? They pass away. If you have a patient that passes away mid-month and you've already reached your 20 minutes, you can bill, but don't bill on the last day of the month like we would normally would, bill on the day before that patient deceased. Medicare will deny the claim if you bill on the last day of the month and they were deceased on the 25th. So voice of experience here, lots of denied claims and you have to correct those. So I would say those two things. We have lots of, we train all of our staff with the exception of those that are completely, so the billing person, we don't train them on chronic care management, but care coordinators, the MAs, anybody who has any clinical touch on or with the patient is trained on documenting chronic care management because you never know who's gonna pick up the phone call and take that call that is about, hey, my hypertension's elevated and can you get this message to my provider and ask them what I should be doing? Should I take more of my Lisinopril or should I take more of my Lasix? And that quick little phone call that turns into five minutes, that all counts of your staff time. All you need to do is note that in the chart and put that in your time tracking in some way, shape or form that it's related to your hypertension. You talked about, the patient called with XYZ questions. These are their blood pressure readings and you documented chronic care management for five minutes based on their hypertension, chronic diagnosis. It's super easy while you're there just to capture that. I always tell my team that, hey, we're doing the right things for the patients. We're doing all this work anyway. We might as well get paid for it. And I truly believe that CMS has created this chronic care management for practices like ours and family practices that do a lot of work in managing the patient that isn't face-to-face. And if you're not capturing it and collecting revenue for it, it's really hard. This is a hard business to make money in and to be profitable. So this was game changing for our practice. Yeah, and we included a couple of documentation examples. Again, that's usually one of the biggest questions I get. This is Tammy's practice. So examples, I'll let her speak to it. But just don't forget, don't just put five minutes or 15 minutes phone call with daughter. Describe the clinical activity. Hopefully they're doing that anyways, because you need to know what happened to go back to your EMR, but that's my word of wisdom here is just be specific on how those minutes are being spent throughout the month. Yeah, these are actual patients and actual documentation directly out of patient's charts as recent as a week or two ago. So as you can see, you can just read through, patient's daughter, Anne, called requesting results from CT scan done on Friday. So a patient care coordinator took that message. She passed it along to the provider. The provider then documented provider called daughter and read. So this is like the patient or the patient care coordinator documented patient daughter and called once the results, messaged that over to the provider. Then the provider tagged on to the bottom of that message and said provider called daughter and reviewed CTA results at length. Consultation was made with our doctor who is a medical director. So she called him and consulted with him about the test results. Then referral was made to neurology and endocrinology discussed with neuro who also reviewed scanned results, 15 minutes. And to be perfectly honest, if she completed this in 15 minutes, I'd be surprised. I imagine she spent more time than that, but she documented 15 minutes total. By the time she did all that, she probably had more time in, but note that she documented what she did, who all she called, what the diagnosis was and how much time she spent. And so that was a combination of support staff and APP, but it doesn't have to be provider involvement. So the second one is, patient called reporting blood pressure readings because on a provider face-to-face visit, they had changed a medication and asked the patient to call the support staff in the office and report what blood pressure readings are. And blood pressure readings were fine. This actually is an MA, I believe, that took this call. And so she was able to say they're trending down, they're doing good. She educated the patient with canned information that we already have for them to present, educate the patient to continue to self-monitor, medicate, continue medications as prescribed, continue low sodium diet, avoid caffeine, contact provider if anything changes. In five minutes of time, they're related to the hypertension diagnosis. So it doesn't have to be provider time involved at all. It just needs to be captured in your medical record. Odds are your staff is capturing this information anyway. So it's just add that diagnosis, add the time. Yeah. And the second example I gave you is again, this 99491, that was that provider CCM. So chances are these were that traditional CCM code. It's a combination, just be the clinical staff. Again, if you're on your own, this could be an example of how easy it is to get to that 30 minutes. The difference between the traditional CCM and the provider CCM, there are add-on codes for both. So you can always get to 60 minutes total, but you must meet a minimum of 30 minutes per calendar month for the 99491. So just another example there. CCM, again, is kind of a big topic to handle. Don't let this scare you, please. You know, when we're talking about all these requirements, again, if you plan it out, you work with your team, you adapt as needed. It really is easy to, you know, map out a workflow and then optimize this. And again, like Tammy said, this is just getting paid for the work you're already doing. You might as well be paid for your time. But we talked about, you know, being specific. We talked about how important that care plan is. That's a big one. You know, the last thing you want is a CCM audit and them to find out that you have all this revenue with no formal care plans. The consent, obviously. I thought this was an interesting one. There was, I don't know if any of you follow the targeted probe and educate audits that CMS does. They pick different services and then provided, they audit a set number of charts. And if you pass favorably, nothing happens. They give you two chances to correct it before you would have any, you know, actual formal penalties. But one of the findings that they said is lack of electronic signature on that care plan. And so again, make sure your providers, if your clinical staff are the ones that are helping them draft that based off their visits notes are actually reviewing and signing that care plan. Oftentimes that is insufficient documentation. The other incident, I had a practice that was like estimating and not putting exact minutes. They were using like greater or less than signs and documentation. Again, be exact. And again, it's all of the times throughout one calendar month for each patient once they're enrolled. So again, like Tami were saying, this is why, this is the sustainability. And again, what I bolded is just, it's interesting to me as I was talking about that complex CCM being a higher bar, it actually pays a little bit more, not even a little bit. It pays more to do the traditional CCM than the 60 minutes of complex CCM. Now, if you have 90 minutes, a little different story, but again, don't be, you know, don't feel like you have to do complex CCM just because you have 60 minutes per calendar month, understand the different CCM services and what that adds up to. We don't have time today to talk about care plan oversight in detail. That's kind of the other care management non-face-to-face work. What care plan oversight is, I did give you a resource that goes over it in more details in the My Resources tab for this webinar, but it only is looking at your home health and hospice patients. And there's very specific activities that says this is a billable activity that you can count minutes for throughout the calendar month. And this is a non-billable activity that you cannot count time for. And the other difference with CPO is it's all qualified provider time, cannot be clinical staff, must be 30 minutes. So just make sure if you are doing care plan oversight services, it pays, I believe, about $111, $113. Yes, it can be profitable, but I would only recommend it if you're a smaller practice with a lot of home health patients or a lot of hospice patients. I know, Tammy, you had an experience trying to juggle both of these for one time. Yeah, when CCM first came out, we onboarded with that pretty quickly, but we were already doing CPO and care plan oversight. And we tried for a while to manage both, but it's really a logistical nightmare. And so we just ditched the whole care plan oversight documentation and do everything as CCM because you can use the same communication with home health for CCM documentation. You just can't use everything you can for CCM or CPO. So it was beneficial from a financial perspective when we just went to straight CCM. And again, like she's talking about, don't overcomplicate things. I also agree with her and recommend pick one or the other. I mean, yes, technically you could do both if you separated it out, but it would get really, you can't also build them together in the same calendar as it's bundled. So logistical nightmare to really try and do both, pick one or the other. Nothing wrong with care plan oversight though if you do it correctly. Some providers, especially when they're small prefer it. Here's the code. Again, there's one for home health services and one for hospice. These are kind of what the EMR needs to look like from a documentation perspective. Check out that resource we've given you that goes into it in more detail. But Tammy mentioned earlier in the start of the presentation that they bill for home health certs and research. This is not care plan oversight. It's under like the same section in the code book. So a lot of people get it confused. This is for your review and signature of the 485. When you order home health for a patient and you start and you sign that initial plan of care, that's when you bill the GO180. On the date you signed that initial home health certification if the patient continues with home health after that first episode and you recertify the patient for home health, you bill the GO179 when you sign the recertification for that patient. The only sometimes hiccup with the GO179 is it does have to be exactly 60 days apart. So if your home health agencies are super behind at getting you those orders, that can cause some headaches. I used to always have to throw a few out when I was in the practice. So work with them on electronic signatures or can they get it to you timely? But again, this is work you're already doing from a documentation perspective. Medicare wants that communication in the EMR and you must keep a copy of that 485 and assigned you're doing that already, hopefully. Anything to add there, Tammy, before we move on? So TCM, and a lot of practices, again, before CMS made this easier to bill and increase the reimbursement, we're doing it, but it's a great clinical framework. I mean, CMS increased the reimbursement and unbundled TCM with all care management services. We used to not to be able to bill CCM and TCM for the same patient within the same month. Now you can, because they believe in the care model. They believe it reduces readmissions when you have a clinical framework that supports this service. So you can not do it for ER visits. The patient does have to be admitted, but both inpatient and observation hospital stays, or if they come home from a skilled rehab stay, a lot of people don't realize that qualifies for TCM as well. So those are what we mean when we say qualifying discharge. You do have to have some sort of licensed clinical staff. Notice the difference here. CCM is a clinical staff. This needs a licensed clinical staff to do that interactive contact call to the patient or caregiver within two business days of their discharge. Give you a template for that, checking in on their needs, how they're doing, must be clinical in nature. And then because TCM is technically a 30-day service period, face-to-face service, the post-discharge visit is the face-to-face service, and then aspects of non-face-to-face services that you wanna have documented. And we're gonna go over that. So again, the only hiccup with interactive contact, if you're not able to reach the patient, CMS did say as long as you have two failed attempts documented in the medical record and you meet all other TCM requirements, you can still bill for it, but they expect attempts to reach the patient or caregiver to continue until they're successful. So you have to call them about the appointment anyways, make your best effort to connect them with a clinical staff member and document this call, because if you don't do it and you don't have the two failed attempts, then you can't bill for TCM services. So this is my recommended template for that clinical staff call with the patient. And again, what I'm doing is looking at all of the Medicare requirements and putting it in a template. So that you're capturing those non-face-to-face services. And this is also meaningful for the provider. The clinical staff is gathering information that's sent to them in advance of the visit and going from there. These are the different face-to-face versus non-face-to-face services that are expected. Again, TCM is technically a 30-day service period. The goal is to avoid that readmission, but you're doing all of these things already. You just need to make sure that your EMR is set up to document it. And then that face-to-face visit. So when you go see the patient for the first time, so they got home from the hospital, your clinical staff contacted them. Now the providers, they're making their visit. That's when they build the TCM code. TCM includes one face-to-face visit. You cannot do an E&M visit, your normal home or domiciliary CPT code and TCM on the same day of service. That first initial post-discharge visit is your face-to-face visit. If you have to go back and see the patient a couple of weeks later, because it's medically necessary, then you can build a follow-up E&M visit when you return, but you have to have one face-to-face visit. And that's when that code is actually dropped. And we're gonna talk about the different MDM requirements, but here's the template that I would encourage your providers to use. And I've also actually given you a clinical documentation example for TCM services where we have this completed. Dr. Chang from HGCI helped me kind of create one for a mock patient. So you can check that out as well. Here's the reimbursement. So again, it used to not be make as much sense. It does now. You use 99495 if you've met in moderate medical decision-making and you saw the patient within 14 days of discharge. You use 99496 if you got there within seven days, but you also, your provider needs to use their discretion because you also have to support high medical decision-making for that TCM visit. This could be new or established patients. Again, ER visits do not count, has to be a qualifying discharge, or if they're going from an assisted living setting to home, that also would not count. Here are the other things. We know that sometimes getting prompt notification of our discharge can be a challenge, certainly providing that education. Hopefully we've given you all those resources that you need to on templates. You also need to have a process within your practice to allow for acute and urgent visits. TCM is one of those reasons on why you would want that. Document and complete that interactive contact call, and then think about how this could be part of your clinical workflow. You know, are you reviewing hospitalizations or recent hospitalizations during those IDT meetings and making sure that those patients were scheduled and seen for their TCM visits? Let Tammy talk about how this works in her practice. Yeah, we have had a TCM workflow in place for years before it was as profitable as it is now. We focus the majority of our TCM efforts on really partnering with our local hospitals to keep those patients from readmitting. And so we're really focusing on key diagnosis such as COPD exacerbation and congestive heart failure. But Bredon has put everything together for you. Definitely macros are so important here. We macro out both for the initial contact from our MAs and then also for the providers. There is a specific transitional care management provider note that cues them on all the information that needs to be there and how that needs to be documented. Remember that transitional care management is also a good time to review an advanced care plan. I'm going to keep plugging advanced care plan. It's kind of my soapbox, if you can't tell yet. And we'll talk more about that in just a second. Happy to answer questions about this in the last 30 minutes, but I know we're pressed on time too. Yeah, so advanced care planning, Tammy's buzzword of this presentation, but I mean, they're really important. Again, please share in the chat if you're billing for this already. It is a time-based services, but you're having these conversations. If you're providing medical care in the home for this complex population, this is when you're discussing the patient preferences, what happens if they can't make decisions for themselves. Every time there's a status change, like Tammy said, there's no limit on how often you can bill this. With or without the completion of the forms. I've gotten questions before on, well, what if I don't fill out the post or the most, or it doesn't get completed? That could be completed during advanced care planning conversation, but it also might take several conversations to actually complete that. So here's the codes. Unlike CCM, where you have to meet that total minute threshold, when we have time-based codes that don't have a minimum requirement, CPT says a unit of time is obtained when the midpoint is passed. So because 99497 is first 30 minutes, as long as you've spent at least 16 minutes on that advanced care planning conversation, I do need that time documented. It has to just solely be dedicated to that conversation, then you can bill for it. And annual wellness visits are a great time to bill for advanced care planning, because if you do it during an AWV and you use modifier 33, then it waives the co-pay for the advanced care planning for the patient. I know that can be really frustrating for patients to have that co-pay for advanced care planning. It's something other advocacy organizations, as well as HCCI has tried to encourage CMS to get rid of in the past so far with no success. But here's my recommended template for what that conversation should look like. Again, be specific. What were the patient preferences? This could be in your, it's gonna be in your E&M note most likely. This is also right now during the public health emergency on Medicare's list of telehealth services, and it could be provided as audio only. So another thing to keep in mind while we still have the PHE flexibilities. And then the consent is usually the sticking point. If you actually read the CMS fact sheet and the language, what they want is documentation for the voluntary nature of this discussion, that the patient is consenting to have an advanced care planning conversation. They understand that what they mean. They encourage you. It actually says that in the fact sheet, they encourage you to let them know there may be a co-pay if it's not part of an annual wellness visit. But this is the template that I would recommend using for that. And then we've also given you an actual documentation example for it as well. I'm gonna skip ahead just a little bit to the slides here and let Tammy talk about how this works in her practice. Yeah, there's just multiple touch points when I think it's very appropriate. Certainly on a new patient visit, it needs to be reviewed and or discussed. If there is a transition of care or change in health status, obviously the annual wellness visit, TCM visit is a perfect time as well. Think about if you have a patient who's moving from home into an assisted living facility, it's a really important thing for a patient to have completed when they move into an assisted living facility. And I wanna just tell you real briefly how we used this in, how I used this in a particular situation. I saw a patient on a TCM visit who severe COPD, post-COPD exacerbation, just home, hospital bed bound, very comorbid advanced illness patient, and no one had ever had an open dialogue with him. And I happened to be in the room with two of his daughters at the time for this TCM visit. So I just initiated a conversation. They had a third sibling that wasn't present. And so they didn't feel comfortable in making any decisions but had the conversation with dad, reviewed the post form that we use in the state of Indiana and left it with them for review, build the ACP visit code or code with my visit that day. Came back two weeks later for follow-up with him and revisited it. Well, they'd had some conversations with the other sister but there was some discussion between them and they couldn't really agree on how they wanted things handled. The dad had one opinion, one of the daughters had another opinion. So they asked a bunch of questions. We had a good dialogue. I answered some questions. We got to some comfortable level of, okay, we're gonna concede to this. But the one sister who was present, who had the questions, couldn't sign. She wasn't power of attorney. So I built it again that time and went back two weeks later, the third visit, and we actually signed the post form. And I built it again, three in a row. But I met the qualifications all three times and documented appropriately. So I just, it's my soapbox. Enough of that. Thank you, Tammy. Again, just understanding the work that you're doing for these complex patients and getting paid for it appropriately. So I know this is a busy slide, but in the world of telehealth, remote patient monitoring will be a billing opportunity beyond the public health emergency. This is not, it doesn't fall under the Medicare telehealth umbrella, where we have to meet those requirements. This is partnering with a vendor though. It's not self-reported patient vitals. And again, it doesn't have to be like a full blown, as extensive as the chronic care management care plan, but RPM does have what they call care episodes, meaning that the patient has treatment goals. And this isn't just endless. They're using the equipment while they need it. For that, whether it's a remote blood pressure cuff or a remote scale or, you know, pull socks, whatever it is to automatically and digitally transmit their physiological data to the practice to be reviewed with them on a monthly basis. And then someone on your team, usually a partnership between your clinical staff and the billing provider are reviewing those readings, communicating with the patients, adjusting the care plan as needed. And again, there's not a prescriptive form with like, these are the RPM elements required, but you do need to document the patient's care plan for remote patient monitoring services and what their treatment goals are. So there's a total of actually five different codes for RPM services. So I'm gonna go through them kind of sequentially on how, when you enroll the patient, you would bill for them. So when you first set up the patient, they're given the home devices and that initial education that goes on 99453 is for the education and setup on the RPM device. 99454 is used once every 30 days because it's a practice expense for the patient to have that device and for those programmed readings to go to the practice. So that's kind of the second code that you would bill. You do have to collect at least a minimum of 16 days worth of data throughout a 30 day calendar period to bill for remote patient monitoring services. The third code that we have, this isn't like an always, you have to use it, but it was interesting when I was reviewing the logic in the final rule, when CMS introduced these services, they said, when the provider first had that first month, they enroll a new patient in RPM services and they're taking the time to review and analyze the first months of data. And maybe they're setting those care goals at that point and documenting that care plan. That could take them 30 minutes. And if it does, you can bill for it, but this has to be all qualified provider time, kind of, again, reviewing readings, developing that care plan could be a good opportunity to use this when you initially start RPM services for the patient, but this is provider time. Whereas the difference with these codes, very similar to CCM, it's a combination of your clinical staff and the provider. Again, you're getting a lot of readings, abnormal readings, conversations with the patient. I've seen, I've heard some really cool stories on clinical outcomes for using these. Again, you have to have a minimum of 20 minutes per calendar month to use the 99457. You do have to be communicating and documenting back and forth with the patient throughout that calendar month. And then there is an add-on code for if you exceed, you know, a total of 40 minutes per calendar month of communicating back and forth with that patient. And again, this, it can be under general supervision. So your clinical staff can definitely help you with your RPM program. It does take you partnering with a technology vendor. Again, you need those remote devices, some Bluetooth, some cellular. Think about the patients you care for. This shouldn't be given to every patient that you have in your practice. And the equipment that you choose should be geriatric friendly or complex, you know, patient friendly. So think about your use case. Is it gonna be hypertension and COPD, or is it gonna be, you know, patients with recent medication changes or unmanaged CHF? And then think about the care time responsibilities and take the time on setup to educate the patient and caregiver on how to use it if they have to hit a button to turn it on. So you're getting that 16 days worth of data. And then Tammy rolled out remote patient monitoring. And so I'll let her talk about how this works in her practice. This is one that we haven't been doing a real long time. We rolled this out last summer. So we've been doing this less than a year. Key points that I don't do, or that I do, I don't give a full remote patient monitoring kit or setup to every patient. So it is diagnosis specific. So if I'm monitoring your hypertension, and that's the reason we're starting remote patient monitoring for you, you're only gonna get a blood pressure cuff. You're not gonna get a blood pressure cuff, a pulse oximeter, a scale, and the whole nine yards. And the key diagnosis that we use for remote patient monitoring is poorly controlled hypertension, congestive heart failure, COPD and COPD exacerbations. And then most recently with COVID and post COVID conditions. So we are using some remote patient monitoring with some latent COVID effects and that sort of thing. And it's been quite useful. But remember with remote patient monitoring or remote, I call it remote patient monitoring, with RPM, that you can't just put the device in the patient's home and just leave it there and build Like Brianna said, you have to have goals of care. And once that patient is meeting those goals of care, that device needs to be removed from the home. But it's incredibly useful. We've been increasing our numbers and there's some investment costs with having the equipment, whether you purchase it or whether you lease it, there's still costs associated with it. But this is one where I think it's highly beneficial in managing your patient population very well. Having an intervention that's there monitoring the patient when you're not and can really be impactful in limiting ER visits and hospitalizations. So this is a big clinical impact. Absolutely. And there's lots of options for technology vendors and things. I feel like I hear about a new one every week, just about. So I mean, again, do your research, talk to your peers, see what's worked well for other people of similar practice models. So you make sure you pick a quality. But again, every little bit counts in fee-for-service. You can build remote patient monitoring and chronic care management as long as the time is separate and distinct. Some programs like to have different RPM staff that's really specializing in that. So it's not too overwhelming and they're not, you just can't, what CMS calls double dipping, right? You're counting it as CCM and RPM minutes. Nope, it's separate and distinct work. It's one or the other. But again, this could be very helpful for you when we're thinking about fee-for-service revenue. And we spit a lot of information at you. I didn't talk about telehealth today because I think hopefully at this point we're a little well-versed, but we did provide you with some resources that go over all of this information and the codes in more detail, again, in your information hub. So I guess as we, we're gonna talk through the slides a little bit, but Timmy, how do you, we talked about a lot of work and a lot of different rollouts. So how do you communicate with your team and how do you kind of make sure everyone's on the same page and have these things go seamlessly? Yeah, so I think the key is communication, communication, communication, and transparency. As a leader of a group that grew and got fairly good size for this type of practice and then ultimately was acquired most recently by Village MD, I think the biggest thing that your providers wanna know is if you're always harping on, we'll add this code or build this or do that, they think you're all about the money. Ultimately, this isn't about the money. This is about providing exceptional patient care to folks that otherwise fall in a gap and don't get that without over-utilizing an emergency room or a hospital. And so what we're really trying to do is find exceptional ways to deliver that care, going above and beyond and getting paid enough for it to be able to keep our doors open. Nobody's getting rich off of home-based primary care if that's where you're in this, you're in the wrong industry for sure. But what we're trying to do is keep the doors open and be profitable enough that we can provide the type of care that we all want to provide to these very sick patients. So transparency, talk about your numbers, talk about your bottom line. Don't be afraid to share that. I say over-communicate. Consider time bonus to performance, performance in quality measures as well as capturing the codes. Never incentivize inappropriate billing or inappropriate coding, but incentivize if you're doing the work, then capturing that code and putting it there. There's nothing wrong with incentivizing, making sure that every annual wellness visit gets an advanced care plan conversation too. Medicare designed it that way and wants it to be built that way. It doesn't cost the patient a penny. So definitely look for those types of opportunities. Yeah. There's my two cents. I think communication and transparency is the big one. The only other plug I'll make is I really believe in ending every meeting, every staff meeting or team meeting with recognition or some sort of positive. Maybe it's a patient story. Team morale is important. So I would love to hear in the chat too if you all have other ideas on how you motivate your team. This next slide was from a previous presentation when Dr. Paul Chang and I were talking about what's the secret sauce to a great team, right? Like he's had his team and Tammy's got an amazing team for so many years now. Like what does that really take? And you'll see, again, that open communication, that competency, people understanding what other people do and making sure there's not duplication, that buy-in of the practice mission. At the end of the day, why are we all here doing this work? And again, when we talk about numbers and data, it's not to just make money. We care because we wanna be here providing great care to our patients. So how do you recognize that and really have everyone understand how each specific role makes a difference in that? And like I said, communication, transparency, I think all of that is great. I promise I am being mindful of time. We're still gonna have at least a full 20 minutes for Q&A, but this I think will drive some of our Q&A. So I wanna set up this conversation. The team is gonna put some links in the chat, but if you have not already seen the CMMI strategy refresh white paper, and there's also a fact sheet if you don't wanna read all, it's long, lots of pages on a summary. It was very encouraging. Here we're talking about this whole webinar and how can we do everything we need to to get this fee-for-service revenue for providing really important care to vulnerable populations and it being really hard to make money. So I think value-based care is the light at the end of the tunnel. And CMMI has a very bold objective where they actually came out in this white paper and said by 2030, they want all Medicare beneficiaries to have some sort of accountable care relationship where providers have some sort of stake in their quality and cost. So again, 2030 might sound far away, but we're getting there. We have models like direct contracting, which is going to become ACR-REACH. The only thing in healthcare that constant has changed is of 2030, the current performance year for direct contracting is wrapping up. And then we're going to the ACR-REACH model. And if you subscribe to our newsletter, you'll see on the differences between this that was released in our newsletter and it's on our blog on our webpage as well that goes into this in a little more detail. And the link at the bottom is to the ACR-REACH page that CMMI did a very nice webinar going over the differences on this model. No one in the call said they're participating earlier. This isn't an active new participation opportunity, but we do have two cohorts of primary care first. Again, it's not specific to home-based primary care, but it's very well aligned where practices are getting paid a PMPM or per patient per month, per member per month, per patient per month flat fee based on their HCC score, the average HCC score of their population. And then they're just getting a lower flat visit fee for each face-to-face visit and the potential for a quality bonus based on these measures. So even if you're not participating, if value-based care sounds like Greek to you, I would encourage you to just take a look at these models and think about, look at the similarities. Thank goodness we're starting to see some more relevant, advanced care planning, days at home measures for this kind of population. So get familiar with it now and think about what it would take for you to be successful so you're prepared for success when that opportunity does arise. So before we formally transition, I do want to pick Tammy's brain a little bit. I just wanted to kind of cue this up as a discussion side. And so you talked a little bit about what specific payment arrangements your practice has at the beginning, but can you talk a little bit about the pay for performance or anything outside of fee for service that you have in your practice? Oh, you're on mute. Sorry, Tammy. Sorry about that. Yes, definitely. I encourage everybody to look for pay for performance opportunities. Certainly within the state of Indiana, UnitedHealthcare has a great program. We also have through Optum programs with Anthem, Humana, Aetna. And although they're not phenomenal increases in payments, when you prove your worth, then you can go to those payers and say, hey, I'm only taking care of the sickest of the sick. I'm seeing the patients in our homes. Let me have your sickest of the sick and give me a PM. And sometimes they will forego their minimum threshold of your panel size because they don't know what to do with these patients either. And so they want the help, but you have to kind of establish yourself and show that you're recapturing those appropriate HCC codes, that you're managing the patients well, that you're decreasing risk, that you're keeping them out of the ER and that you're keeping them out of the hospital, that you're performing those routine annual wellness exams as are appropriate. And that if you're not getting mammograms and colonoscopies and that sort of things, it's because you have frailty codes to negate the need for that coded out for each patient. So look for opportunities along that line, be aware of your own practice model and what you can do and what you can't do and how that may hinder you in working in some of these advanced payment arrangements. That's where I'd start. And then one last question for you, Tammy, before we let others jump in, any tips for success? Was there new things you had to do to your care model when you were thinking about value-based care or trying to think about taking on risk? Any specifics on practice infrastructure or clinical standards that are important? Well, I think really making sure that you understand HCC coding and that you're really capturing those risk scores well is the biggest thing. Knowing that a toe amputation is so important to document and to code out on an annual basis and that every January one, this gets wiped clean and you have to start over every year and risk stratify those patients, risk score them out. So I think that's the biggest. And one of the other slides you had up, Brianna, she said something about healthcare and change. And if you're change averse, then you're still in the wrong industry because there is one thing for sure about healthcare is it is always changing. So I wanna say hats off to all of you for being here. I have found HCCI over the years to be an incredible resource for me and they'll help lead you to the right things. They certainly have me and our practice. So kudos to you all for being in the right place and putting the time in to learn how to do it the best way. You're doing the right things already. All right. Well, thank you, Tanya. With that, I'll turn it back to you, Dana. Great. Well, thank you guys. Again, I have captured some questions that happened during the conversation or the presentation. I am gonna encourage you all to open up your videos so we can see faces. And also after I ask these questions in the chat, unmute yourself and let's have some very active discussion. I think that would be great. The first question that we have is, do you have to be certified to bill for smoking sensation? No. So that's just the smoking sensation code is when you spend a minimum of four minutes counseling the patient. I'm gonna take the slides away for now so we can see faces. But that's when you have a conversation, counseling the patient to stop their tobacco use, risk and benefits, and it lasts at least four minutes. But it has to be a provider, if that's the question. I'm sorry. So MDPANP. Okay. The next one happened around CCM. What about routine care plan follow-up? So I think Tammy talked a little bit about that. I don't know if you wanna get into kind of when you update it, but again, the requirement from CCS, CMS, excuse me, you have a date for periodic review. And like Tammy said, anytime there's a substantial change in the care plan, do you have any other words of wisdom specific to that, Tammy? You can do it a couple of different ways. You can tack it on to something that happens every year, like the annual wellness exam. I find it difficult to tack on to the annual wellness exam. I think the annual wellness exam takes a good piece of time anyway. I know other providers who do their annual wellness exams in 20 minutes flat. Mine takes 45 minutes to an hour almost every time I do it, just because I'm making sure that I'm going that deep with the patient and the caregiver and really talking about all those things that are concerning and making sure we're reviewing the advanced care plan and so on and so forth. So I don't add it on there, but what I will do is once I've done the annual wellness visit, I schedule another visit to come back and review their chronic care management care plan. I schedule it. It makes sense for me. And that's what works in our practice. You just have to figure out what works in your workflow. And I think I get the question now with, I saw the clarification in the chat. So no, there's no requirement that you have to like call the patient every week. I think what you're getting at is I know some programs that like schedule CCM calls. I mean, again, CCM is really supposed to be organic care that happens in conversations throughout the month. You could schedule it if you wanted to sign clinical alerts for your clinical staff to check in on patients as needed. It's not that that would be wrong, but the requirement of the care plan is after it's drafted and finalized and you go over it with the patient and caregiver that they have a copy of it and any other healthcare professionals involved in their care have a copy of it. And so you may, after the first visit, want to have someone call and go over it with them, but that's not, you know, hopefully you're doing that in the visit. That's not like a hard requirement that you have to call them every time you formally update the care plan. Yeah, and I'm not sure I don't see them on here now. I don't know. I saw a chat come up earlier from Taylor Rogers. I think that they were working with Bluefish through NextGen for their chronic care management. And I've not worked with a third-party vendor that does it externally. So I want to throw a question back to you all as a group. Those of you that do work with a third-party vendor that does your chronic care management, are you having staff also participate in that? Are you putting all of that responsibility on the third-party vendor? Anyone? Don't be shy, we're all in the same boat. I don't have any experience with that, so I can't really speak to it. We've always done it in-house. Hello, this is Ade from Alaska. Sorry, I can't be on camera in a really uncomfortable place, so I apologize. I will say that I actually had staff until recently doing chronic care management. It was wonderful having care managers able to just reach out to the patients and phone calls and all of that. However, what I found was it was so hard to keep staff just because of the cost. So unfortunately, we had to let our care manager go. That's been the biggest challenge for me. My panel has increased in size, so it'd be great to continue it, but I'm just trying to figure out how to do it while being able to employ good people to stay and do this. Hey, the healthcare industry is tough right now, and keeping good employees is hard, I get it. And thank you very much for giving some feedback. I appreciate that. Yeah, I am sorry, Ade, I would make- Sorry. Oh, go ahead, someone, go ahead. No, I was just gonna say, so we actually have hired an RN for the position, but the RN does both CCM and TCM, and that was really mostly to justify the position with the revenue that would be generated through CCM. So we do have a dedicated person. I mean, that's perfect case scenario, right? It would be great to have a dedicated person. I mean, Ade, I would say in your situation, maybe start with the provider CCM, again, just capturing it when you're doing it already, as a start, and then maybe you'll get to a point where you can hire those care managers back later on. Thinking about what licensures you hire to, an RN's gonna be more expensive. If we're just talking about chronic care management, that could be someone like an MA, if you train them and invest in them. The only thing I'll, Tammy, to your question on third parties, there is some language in the CMS FAQ on that. They are discouraging like fully outsourcing CCM, because again, there does need to be some billing practitioner involvement. It's not that you can't use. I do know some practices that use a third party because that's how they document their CCM time. And there is some involvement when they don't have staff of their own. So again, maybe that kind of tags onto a days where they can use the clinical staff from the vendor. But if you're going to do that, I need to see documented involvement. It can't just be the third party. What CMS is starting to catch onto is these third parties that are just saying, hey, we'll do your CCM and billing for it when there's not that partnership and there's not that care management. So I would just be a little careful with that and make sure that, you know, if you are using a third party, that it truly is a partnership and they're acting as an extension of your practice and check out the language. If it got updated, I gotta love CMS with their documents. I had to copy and paste a lot of these things in a certain thing. So they're always taking those down, but you can actually go to the CMS care management webpage and they usually have all of that there. Yes, you're right. I see your question. And yes, the provider would need to create the care plan, but then the MA could make updates to it. And yes, so good point, correct. Yeah. I think the next one is a question slash clarity. And I believe it happened around CCM. Are the documentation examples with time and diagnosis and plan, was that in a patient plan like the telephone number or was that in the chronic care plan? So the wonderful thing about ours is it kind of all merges together. Our EHR, it is a patient note. So it's in the actual patient chart, but then because we designate it as specific to diagnosis in amount of time and that it's a little, there's a slider that comes out and you have to designate, this is a CCM note. And so then it designates, this is a CCM note. When you go pull the CCM care plan, it will pull over a list of all the things for the month that you addressed with the date and the note that you made and the amount of time that you allocated. So it pulls actually a log that attaches to your care plan. So you have a nice audit trail, should you ever get audited. And yeah, it certainly doesn't have to be in the care plan. I mean, most of these are gonna be telephone calls or care management calls, but that's where it's helpful to have that CCM module or some sort of systemic process like Tammy is saying, because what I don't want you to have to do is then go find all those telephone calls. You should be able to run a report if you have that tag of the total minutes at the end of the month, but then you can feel confident that they're documented. And if you're EMR, again, just ask them, do you have a time tracking module? Like that slider that Tammy mentioned, every encounter you open will have a spot for you to add minutes for most of them. I mean, I know every EMR is a little different, but I've seen a lot of good ones. I have two more pre-submitted and then I'll open it up to see if anybody's ready. How often does a provider need to sign the care plan for CMS not to pursue for auditing, for more auditing? You know, I will say as much as, and I get it, and I appreciate actually the compliance culture that is present on this call right now, but CMS likes chronic care management. They are endorsing it. They created the service to support primary care for all of this management that's doing. Again, the CMS requirement is date for periodic review. So I want it signed after it's created and implemented or viewed with the patient. And then usually your EMR will have a date, you know, when it's updated or a new signature date. So I would say at the very least once annually, and again, it doesn't even say annually, it says date for periodic review is the actual hard CMS language. But as Tammy said, you know, typically that may be more frequently, but annually is, you know, date for periodic review. I would say at least annually would be the requirement on the formal care plan. You're gonna have all of that other communication with the patient and your visits and other things that are happening outside of that care plan. That's just part of your daily work. Okay, I think that got us through all of our questions. Are there any brave people who want to ask live? You don't have to turn on your video, but it looks like Tammy has one, go ahead. I do, I caught one of the comments that came up in the text string and I really want to address it because again, near and dear my heart. I get that consenting a patient for billing a advanced care planning is an uncomfortable situation. Here's one little tidbit that you might use. If you go to an attorney to have your will drawn up and you go through creating a healthcare surrogate and you talk to that attorney about your advanced directives, do you have any idea how much money you're gonna pay to have that done? It's a lot. This is a form that the state gives free that the provider has the capacity to sign so that there's no attorney involved and it addresses at a better medical level, everything that needs to be addressed for advanced care planning. It's so much cheaper than going to an attorney or having any other method of having that developed. And if they pay $8 as a co-pay once or twice, it's a whole lot cheaper than having it drawn up in any other legal format. Is it free? No, but in the big scheme of things, it saves so much money. And to have these conversations and to make these choices before that patient goes to the hospital and has exorbitant co-pays because services were delivered that the patient didn't really want, it actually saves money in the long run. Have the conversations. I know they're tough, but find a way to be comfortable with it and talk about those things in a loving, caring way and your patient will thank you for it, I promise. And like I said, you can change that scripting and create the scripting and have Mark at a staff meeting talk about how you're gonna approach it with patients and things like that. Because again, these are important conversations. And as far as letting them know about the co-pay specifically, that is encouraged, but you're consenting them, like, hey, we need to have a conversation. Whoever's answering the phone should be comfortable with fielding those questions too is the only thing I would say. When you get those billing questions, hey, I have this extra service I see on my bill and I don't understand what this was or this wasn't a face-to-face visit. How are you preparing your staff to address those questions or go over the types of services you bill even at any patient visit? So it's not a surprise. And there have been times when I'm in the home and I say, hey, I wanna talk to you about advanced directives, advanced care planning. This is something that I'm gonna charge a fee for. It's gonna be covered by your insurance, but only at 80%. So there may be a co-payer deductible associated with it. Are you comfortable having those conversations? I've got some forms here. We can go over them. And they tell me straight up, no, I don't wanna talk about that. Okay, let's not talk about it. I can still document that I attempted which means I've done the right thing for the patient. And I'm not gonna charge that. I'm not gonna build a code, but I know I've done the right thing for the patient. So I could tell you personal stories about why this is so important to me, but I won't waste our time on that. We did have another one pop up. Can a provider who is not the patient's PCP bill for CCM? So with that, you would have to be managing all of the patient's chronic health conditions. So that would be difficult. But what I would look at, if this is like a palliative care practice or you're not the primary care provider, there is a similar service called principal care management, PCM, P as in Paul, CM services. And I go over that in our advanced coding opportunity resource handout that you have access to. That's only a comprehensive care plan for a single high-risk disease, whereas CCM is for all of the patient's chronic health conditions that you manage. So if you're not the PCP, then PCM services might be a better fit for you. Okay, anybody else want, oh, what do you think about the five wishes form, Rachel? Yami, do you wanna talk about the five wishes form? I have not started using that in my own practice yet. We're getting ready to. I love it. I think it's great. Yeah, I mean, I can say I had a practice that I worked for that used it, and I have personally used that with my own family members, and I just think it's made it a lot easier and it's amazing that it has it there. So I also, I'm not clinical and I don't pretend to be, but I like the five wishes form. I'm gonna take a minute. Rachel Jankowski is on the call wave. She's on my team. She's the manager of outreach and engagement for HCCI. Previously, I know she used this form. We've talked about it before, so I wanted to give her a chance to chat about it here. Sorry to put you on the spot, Rachel. No, that's okay. Hi, everybody. Nice to see names and some faces. I am also not clinical, and I don't pretend to play that on TV, but my background is in social services. I have a social service and SNF background directly, and then I did business development and dabbled in some care coordination in a hospice setting too, and home health, and the conversation comes up everywhere. It comes up in cocktail parties that I go to and birthday parties for my friends, and every single time I go out, it's always brought up. So I think it's a great resource. It's not always a fun conversation to have. I think it's a conversation everybody needs to have, whether you're in the healthcare space or not. I think we all know what our fate is going to be, and you might as well be prepared for it. So that's, I'm gonna get off my soapbox because I could keep going. So nice to see everybody. We're gonna send you and Tammy on the road. Yeah, right? All right, anyone else have any other questions? Okay, I wanna be respectful of time. Just got a couple more things, and this is really some resources for you guys. We do have our third webinar of this three-part series in April, Empowering Practices, Implementing Internal Coding Actions or Audits and Quality Improvement Plans. So this is where we're gonna have our presenters really break down and say, here's some tools and things that you can actually do in your practice to implement these things. I'm gonna remind you guys for the fifth time, you can switch the slide, Brianna, that you will have all of these resources in your HCCI Learning Hub. You'll have the presentation, you'll have a recording, you'll have a multitude of supplemental handouts. Don't forget that if you did register with a three-part series, you also have access in your specific bundle for free online courses and some other additional resources. So please go out there and check those out. I know you guys got a lot of information today. We at HCCI, I wanna stress, we're a nonprofit. This is work we do because we're passionate about it and the people who support us financially are passionate about it. And what we make sure that we do is we have the right people and the right resources available to you guys who are doing the really hard work. And that is a hotline. You have a phone number, an email. You got a question that we didn't cover today or something later, feel free to reach out to us. We do have these webinars every other month. We will have premier from time to time, but we do mostly have our regular free presentations and we'll keep you guys up to date on that. And then if you haven't checked out our HCCI Intelligence Tools and Tip Sheets, it is a plethora of downloadable tools and tip sheets that you will find that are very informative, concise, intuitive, and some things that you will be able to actually implement into your practice. So that was my soapbox because I want you guys to remember where we are and take us up on our offer because as you can tell, we're extremely passionate about what we do. Rachel is also, you heard her talk earlier, she's on my team as well. And you can find any of us at any time and we'd love to chat about home-based primary care. It's our passion. So I do wanna thank Tammy for bringing your experience, bringing your voice, Brianna, obviously, again, just some wonderful information. Brianna is who you will likely get on that hotline. She's probably gonna kill me when I tell you that, but wealth of information. And I do wanna thank you for joining. I know that you guys now more than ever are so busy and there are a thousand things on your plate. So we appreciate that you trusted us to give you some knowledge today. And it was really great. And we hope to see you back in April. Yeah, thank you everyone for the- Thank you everyone. Bye-bye. Thanks everyone.
Video Summary
In this webinar, Tammy Browning and Brianna Plintzner discuss various payment opportunities for home-based primary care providers, including chronic care management (CCM), transitional care management (TCM), and advanced care planning. They emphasize the importance of understanding and accurately documenting these services to maximize reimbursement. The presenters provide examples and tips for incorporating these services into workflows, and they discuss the benefits of partnering with third-party vendors for chronic care management and remote patient monitoring. They also highlight the upcoming shift towards value-based care and encourage providers to familiarize themselves with models such as Direct Contracting and Primary Care First. The importance of communication, transparency, and recognizing the contributions of the team in achieving successful outcomes is emphasized. The webinar concludes with a Q&A session addressing various topics related to smoking sensation counseling, routine care plan follow-up, provider signatures on care plans, and billing for CCM by non-PCPs. Additional resources are provided, and participants are encouraged to seek further support.<br /><br />Credit: The webinar is presented by Tammy Browning, President of Grace at Home, and Brianna Plintzner, Senior Consultant and Manager of Practice Development at Home Center Care Institute.
Keywords
webinar
payment opportunities
home-based primary care providers
chronic care management
transitional care management
advanced care planning
reimbursement
workflows
third-party vendors
remote patient monitoring
value-based care
Direct Contracting
Primary Care First
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