false
Catalog
HCCIntelligence™ Webinar Recording: What You Shoul ...
Webinar Video
Webinar Video
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Hi, everyone, and welcome to our monthly HCCI Intelligence webinar and virtual office hours. We're right at the four o'clock hour today, so we certainly want to make sure that we are aware of everyone's time and get a good start. Today's webinar will be presented by Brianna Plentsner, CPC, CPMA, and is entitled, What You Should Know About 2020 Coding Updates. My name is Danielle Feinberg, HCCI's Coordinator, Education and Research, and I will be your moderator for this event. Before we formally begin, I'd like to cover a few housekeeping items with you. The first portion of our webinar will be dedicated to the formal presentation. Participants are absolutely welcomed and encouraged to submit questions, but we will address these questions at the end of the presentation and during the open virtual office hours following the webinar. The questions submitted do not need to be directly related to the topic of the webinar, but can cover any topic that you wish. If you would like to submit a question, please do so by clicking on the questions box located on your screen and typing in the question. A copy of our presentation is available in the handouts box and can be saved by clicking on the name of the presentation and downloading it. All registrants will receive a copy of the slide deck, questions and answers, and a recording of the presentation. Additionally, these will be made available on our website on our HCC Intelligence page. At the conclusion of our virtual office hours, which immediately follows our presentation, I will send out a brief survey link via email. We appreciate your feedback, which gives us an opportunity to understand your needs and decide on meaningful future webinar topics. Today we are joined by our presenter, Brianna Plentsner. Ms. Plentsner is the Manager, Practice Improvement for the Home Center Cared Institute. She has deep knowledge and experience in house calls practice management, having focused her career in primary care and home care medicine. She's a certified medical coder, certified professional medical auditor, and holds a diploma in medical insurance, billing, and coding. Prior to joining HCCI, she served as a practice manager for home care physicians, a house call practice that is part of Northwestern Medicine in Chicago. Ms. Plentsner excels at developing workflows and efficiencies for home-based primary care. We will also be joined by Dr. Thomas Cornwell, HCCI CEO and founder of Home Care Physicians, and Dr. Paul Chang, HCCI Senior Medical and Practice Advisor and Medical Director for home care physicians when we transition into the virtual office hours portion. Without further ado, I'd like to turn our presentation over to Brianna Plentsner. Thank you, Danielle, and thank you everyone for joining us this afternoon. This is our webinar as a result of the Medicare Physician Fee Schedule Final Rule for 2020. So our objectives are to discuss the 2020 coding changes and the implications that that might have on your practice. We're also going to review the documentation and coding requirements that are needed to maintain compliance when you're using these services. And then we'll talk about the CPT codes related to care management services, as those are most relevant to home-based medical care. So before we start, I do want to say everything that I'm going to discuss today is from Medicare guidelines. So remember, if you deal with managed care or commercial payers, they may have some different interpretations, and it's also going to be important for you to check with your local Medicare administrator contractor for any new guidance on these services as it becomes available. But these are the federal guidelines that CMS puts forth. So we're going to talk first about chronic care management and the changes, but I wanted to start by just a reminder of what chronic care management looks like today. So the services that you see on the screen, CPT code 99490, is commonly referred to as traditional CCM. This is within a calendar month when there is 20 minutes of both clinical staff and your provider time, and that's currently valued as the national payment rate of $42. We also have CPT code 99491, which not everyone realizes exists, but this would be for a scenario if you as the provider, physician or nurse practitioner or physician assistant, are spending 30 minutes of just your time during that calendar month for chronic care management, you would bill this code instead of traditional CCM, and that's valued at about $84. That's the national payment rate. And then, of course, we have what's referred to as complex CCM, and those are reported with CPT codes 99487 and 99489. And the difference with these services is it requires a minimum of 60 minutes per calendar month, and prior to this year, we're going to talk about the change. The care plan had to be substantially revised and medical decision-making of moderate and high complexity, and then 4899 and 489 would be the add-on code if an hour and a half of that combined time was spent during a calendar month. So this is CCM as it exists today. Another important consideration, and this question actually came up recently as a conference, is CCM is not just capturing and documenting your time throughout the calendar month. During the final rule, they provided these graphs, CMS did, which I think did a really nice job of just kind of outlawing in a graphic the requirements. You do have to get verbal consent. That's never going to go away. It could be verbal or written. If it's a new patient, meaning it's a new patient that you haven't seen within the past 12 months or new to your practice, you do have to get permission and talk about CCM during an initiating visit before you could bill for it. The practice does have to use a certified EHR. You have to have 24-7 access to care, so that doesn't mean that you're going to go make a house call at all hours and weekends, but you do need to have that after-hours on-call service. Patients enrolled in CCM do need to be given a designated care team member, whether that's just one of your primary full-time staff members. One important consideration with this is all of your clinical staff time still counts, so it's not just that one person, and you also want to be capturing the minutes that your providers spend. The requirement is that they do have that designated care team member, so some practices do employ a CCM nurse or LPN or something like that, but you don't have to. You just have to designate someone on your team to be their main point of contact, but you still capture the minutes from all of your clinical staff and your providers throughout the month. The reason why templates are so important is because of the next two requirements for this service. You need that systematic approach to care management, as well as there are requirements for the comprehensive electronic care plan, which does need to be created, monitored, revised as necessary, and provided to the patient and caregiver. You also have to manage their transitions and referrals, any of the community-based services or other specialists the patient may need, and have to provide enhanced communication opportunities, which could simply be their patient portal. So all of these things do need to be in place for patients that you're providing and billing for chronic care management services. Another question that commonly comes up with CCM is, what does that comprehensive care plan look like? So laid out on the screen for you as a refresher, this is what CMS says they expect that to look like. This should look like these fields here, how your template currently looks. There was a minor change. What it used to say is one of the requirements of the care plan was community and social services ordered. Very minor, but they changed that point to be interaction and coordination with outside resources and providers. So just so you're aware of that, again, your comprehensive care plan, though, does need to be a separate living, breathing document, and these are the recommended, you know, fields that you need to have for that. What's new is a G-code, and remember that G-codes are, again, for traditional Medicare. Medicare Advantage payers usually recognize them as well, but they are Medicare services. They've added an add-on code. So this can only be used with that traditional CCM that we talked about. So that's what most practices who do CCM are billing for. It's 99490, that 20 minutes of clinical staff and provider time. What CMS said is they recognize that there might need to be additional time thresholds for you to bill throughout the month. Maybe you're not at that complex CCM level, but you're spending 40 to 60 minutes per calendar month. So what they've done is created G-2058. So that can only be billed in conjunction with traditional CCM, and all those requirements we just talked about, you still have to meet. You can bill a maximum of two units of this per month. So that would equal a total of 60 minutes. So you could bill 99490 and two units of G-2058 if 60 minutes per calendar month on combined clinical staff and provider time is furnished throughout the calendar month for your patients. Now you have to do one or the other, so you can't be billing for this traditional CCM as well as that provider code, the 99491 or complex CCM. It's one service or the other, and this G-code is only for traditional CCM services. And you can see the payment for that is $37. So doing a little kind of cost analysis here, if you were to bill, if you had 40 minutes of traditional CCM time throughout the calendar month, so that means you're billing 99490 and G-2058, that would be about $80 a month per patient that you do this. And think of these complex patients, this is all the time that you're already spending for these patients. Or if it was 60 minutes during a calendar month, and you billed traditional CCM and two units of G-2058, that's going to come out to $118, which is actually a little bit more than the payment for complex CCM. So again, not having to worry about some of those extra complex CCM requirements, and the service does add up to a little bit more reimbursement. Dr. Cornwallapar, did you want to add anything? I thought I heard someone chime in. I was coughing. Sorry. Oh, that's okay. So again, just an opportunity for you to be aware of, as it was before 2020, if you were billing for traditional CCM, whether you went over that 20 minutes or not, you should have still only been billing 99490. Now you have an opportunity with this new G-code to get paid for those additional minutes. I'm going to talk a little bit about complex CCM. So those are the 99487, it would be the first code, that minimum of 60 minutes. Now the change that CMS came out in their final rule with here is they believed that this service was limited because of their language that that care plan had to be substantially revised. So they removed that. They're saying, you know, we expect that there's, you know, very comprehensive care management, I believe is the language that they used going on with these patients, regardless of if that care plan is, quote unquote, substantially revised. So we're removing that language. Now you still have to have moderate or high medical decision making. In my opinion, traditional CCM is a little bit easier. I actually looked at CPT today, and the requirements that CPT says for complex chronic care management is they would expect this to only be used in scenarios where the patient has one of the following. And all of our homebound or home limited medical patients are qualified for this, but I thought it was interesting. They would need a coordination of a number of specialties and services or services. The patients who have complex CCM would have an inability to perform activities of daily living and or cognitive impairment resulting in poor adherence to a treatment plan without substantial assistance from a caregiver. The patient would have psychiatric or other core morbidities such as dementia or COPD or substance abuse, and or they would have social support requirements and difficulties with access to care. So again, that probably sounds like all of our patients, but just so you know that that language does exist when you're referring to complex chronic care management. What is also brand new, and this code did not even exist before 2020, is something called principal care management. Now principal care management is almost identical to the requirements that we have for chronic care management, but the big difference is this would be comprehensive care management for a single high-risk disease, and that disease would be of sufficient severity to place the patient at risk of hospitalization or that one major condition had been the cause of a recent hospitalization, which required the development of a substantial care plan, so a disease-specific care plan. And there's two G codes, one for 30 minutes of combined clinical and provider staff, so not 20 minutes, 30 minutes total per calendar month, or they have a 30 minutes of just that provider time. And in my opinion, the opportunity that I see for principal care management would be for palliative care organizations where you may be really brought in for patients that you are responsible for managing one of their most significant diseases. Maybe this is an opportunity for you. It can only be furnished by one billing practitioner, so just like CCM, you have to get permission for principal care management, and you and another provider couldn't be providing it. But I wanted you to be aware of these new G codes. Again, this is Medicare purposes. I do think there's some opportunity for palliative care providers who might have not been comfortable providing chronic care management but are still doing all of that same care management work to possibly utilize this service. And Dr. Cornwell or Dr. Chang, do you have anything to add on opportunities for PCM? Yeah, my only comment is that, which I was pleased with this, is that in Dr. Chang and my practice, like I think a lot of home-based primary care practices, our average age patient is 80, a third over 85, but 10% are under the age of 65, and oftentimes they have one principal chronic problem, such as ALS, multiple sclerosis, cervical spine injuries with quadriplegia, things like that. And what's nice when they have that one principal diagnosis, it oftentimes does bring other problems, but when they have that one principal diagnosis, this new PCM code will allow us to bill for chronic care management based on what, Brianna, you just said. Great. And so here's the reimbursement for those services. So you have the PCM code of your provider time pays a little bit more at about $92. This is the CMS national payment amount, whereas the GO-265 for that 30 minutes of combined time is $39. Again, very similar to chronic care management, but again, if you look at this table that was provided in the final rule, you still have to meet all those other requirements of the verbal consent, that visit, the certified EHR, everything that we talked about for chronic care management. So make sure that you have an implementation plan before you roll out a service like this, that you have templates, macros to obtain a document that consent, or macros or smart phrases depending on what your EHR uses, that you have a template for the care plan so that all of the required fields are met and that you're distributing that to your patients and caregivers. So next we're going to talk about the changes with transitional care management, and this was quite a pleasant surprise. So TCM has existed. You're probably all familiar with the CPT codes 99495 and 99496, but the reasoning that CMS came out with in their final rule is they felt like this service was still underutilized, and there's a lot of research out there that shows that formal transitional care management reduces utilization and produces great outcomes. So they were trying to think of how they could make this easier and incentivize providers to use TCM. So what they did is they increased the payment and the work car view, and so you can see the increased work car view here. And what they more importantly did is they unbundled TCM with a total of 17 services that it was bundled with, which was a big barrier for people. One most notably is they unbundled TCM, so transitional care management and chronic care management, again, for traditional Medicare purposes only, are now unbundled, as well as they unbundled prolonged services non-face-to-face. That's that 99358 for 31 minutes before or after the visit of that non-face-to-face time. They unbundled that INR monitoring services, the analysis of physiological data, which is a great one. Again, the care plan oversight and TCM were unbundled. So this really does make it a lot easier for providers to not have to worry about all of those bundled services. Again, keep an eye on this, especially with Medicare Advantage payers. I'm a little leery that I want to make sure they catch up with these guidelines, so watch it if you're billing for both CCM and TCM over the first couple months of 2020. But this is really great news, and this grid that I have here, you can see the link on the screen. This is from the Federal Register, the 2020 Medicare Physician Final Fee Schedule, so you can have access to all this information to go back and share with your team. And then the payment, the increased payment, you have $187 now for 99495, so that's when you would see the patient within 14 calendar days of discharge, does have to have moderate MDM, and you still need that interactive contact call, so that telephone check-in with the patient within two business days by your clinical staff, whereas 99496, if you're seeing the patients within seven calendar days of discharge, or I'm sorry, seven business days of discharge, the interactive contact has to be, or no, I'm sorry, it is seven calendar days. The interactive contact is business days. But note, with 99496, you do have to have high medical decision-making, so that means in your assessment and plan, I need to see all those details of what you reviewed, those extra people you spoke with, the multiple chronic conditions, all of those things to get you up to that high MDM level, and that now will pay $247 at that higher reimbursement rate, which was less before, and I will say, though, when I have audited TCM services, sometimes I don't always get to that high MDM if you're not documenting those kinds of things in your assessment and plan. And Dr. Cornwall and Dr. Chang, anything to add? Yeah, you know, I'm actually excited about these changes. I virtually never build these codes, and it was for two main reasons. One, when I did follow-ups, oftentimes it would be moderate medical decision-making, so that would be the 99495, and that actually paid less than the level four follow-up 99350, which also requires moderate complexity. So I would actually get paid more by just doing a level four follow-up, and it didn't require the additional documentation that TCM required, and it didn't bundle any of those other things that sometimes I would use. It was also not uncommon for me to bill 99358 that 31 minutes before and after, because just reviewing all the, in our case, epic medical record from the hospitalization before going out, I would often get a 99358, which where I am pays about $115, and then I wouldn't have to worry about CCM and stuff like that. And so not only did they unbundle all those other codes that I not uncommonly use, but they actually pay more now, so that actually this 99495, the one that requires moderate complexity, actually does pay more than the highest level follow-up visit in our area. And so I think these are great changes to incentivize using this important code. Absolutely, yeah, that's a great point. I think that was a big barrier before. Yeah, and I really am glad to see the, as Tom said, the unbundling that is huge in terms of trying to keep all the complexity out of the provider's head, like did I bill CCM or TCM this month? That just takes that particular challenge out of our minds. And also, of course, the higher reimbursement is also helpful. And also for the providers, I think it will be really important to have a template going into the visit so you can document what you've done for the patient at the visit and get paid accordingly. Yeah, that's a great point. And one resource for any of you on the phone that might not already be aware of our HCC Intelligence Resource Center, we do have a variety of tools and tip sheets that are now available. We have two on TCM, one that lays out what your documentation in that actual face-to-face visit note should look like, so that's your post-discharge visit, as well as a second one for those interactive contact call requirements. Again, with all of these services, save yourself some time and efficiencies and peace of mind that you're staying compliant with guidelines. Take a look at those resources. If you're not currently billing TCM and are considering it, that will be another great resource for you. So lastly, what I was pleasantly surprised about is online digital E&M services. And what we've seen in the past couple years is CMS coming out with more, they classify them as technology-based check-in services or digital communication services that are not considered their definition, Medicare's definition, when I say their, of telehealth, because we all know the barriers to what Medicare considers telehealth of that originating and distant site requirements, patients having to be in that rural or healthcare provisional shortage area. CMS has formally stated they do not consider these services their definition of telehealth, so you do not have to comply with those requirements. What CMS described these services are as patient-initiated digital communications that require a clinical decision and otherwise typically would have been provided in the office. So I'm showing you the slide with the payments and all the codes first because I have two full slides of requirements, of course. So again, you need a well-thought-out implementation plan before utilizing any new services like this. But what I want to point out first is what the opportunities are. So you'll see 99421 through 99423. These would be reported by the provider. So nurse practitioners, physician assistants, or physicians can all bill for these first three services. And it's a cumulative amount of time over a seven-day period. And then there's different codes for how much time is spent. And you can see the payment and work review. They're not significant. They're not high reimbursement. However, if you want to think about remote patient monitoring or some sort of kind of telehealth component to your practice, you finally have a little bit of opportunity to be paid for that. The last three G codes, again, G codes are for Medicare purposes only. There are CPT codes for commercial payers that I didn't put on the screen here because our population typically is Medicare, Medicaid. But this is for non-physician healthcare professionals. And this also does not include nurse practitioners and physicians assistants because they consider that a provider level. These are for providers that cannot bill E&M. So, G2061 through G2063 in the final rule, it says, are for practitioners who cannot independently bill E&M services. So, let's talk about the requirements. With these online digital E&M, they have to be patient initiated. So, you can't be calling the patient or using that virtual visit or grand pad or whatever device you have to check in with the patient, unfortunately. And this could be a little bit of a barrier, but the patient has to be calling you about some sort of symptom, concern, change in their condition. It does also have to be an established patient. So, you can't be using this for new patients. That means they want that existing provider patient relationship that would have already had a formal face-to-face visit. Be careful with this language, too. They're saying that if you're going to bill online digital E&M, it requires evaluation management and assessment. So, it's not for non-evaluative communications if you're following up on test results or scheduling a specialist appointment. So, keep in mind, don't just use this for all scenarios across the board. This is really when you're avoiding that face-to-face visit. You're giving advice, you know, maybe their blood pressure has been a little bit uncontrolled and they're calling you over a series of a couple days with blood pressure readings and you're adjusting medication. To me, that would be a great example of when you might use this. You also have to have a HIPAA-compliant secure platform. That's never going to go away. So, make sure, especially when we're getting into the world of remote patient monitoring and telehealth, everything that you use and everything that you store and the ways you communicate with your patients must be HIPAA-compliant. This also requires verbal consent. So, make sure that's obtained and documented. And again, I apologize for the lengthy slides here, but it's important for you to have all these requirements. Obviously, documentation in the medical record is required. What I would say about that is not just, you know, 10 minutes spent on online digital E&M. It doesn't have to be long and lengthy, but you do need to briefly document what did you do? What did you advise? What was the problem? I've also seen it where it was, you know, like 10 minutes spent talking to patient and daughter. Well, what were you talking to the patient and daughter about? So, make sure you elaborate a little bit. It also cannot be related. So, again, these are for when we avoid an E&M visit and they're not for follow-up questions on that E&M visit that you just had with that patient within the past seven days and typically cannot result in that face-to-face visit, similar to that virtual checking services that we already have. These are not for post-op patients that are still within their global surgery period. And the next bullet is really talking about if that face-to-face visit occurs. So, again, the simple answer to this bullet is if you start, you know, recording your time for an online digital E&M, but then you decide you really want to see the patient face-to-face, don't bill for the online E&M. Bill for your face-to-face visit. That'll take the thought out of that, as well as this is for your time as the provider. Not your clinical staff. So, keep that in mind. And then make sure you're not double counting time. So, if you're doing this with another care management service, such as anti-care regulation management, you can't, you know, double count your time or bill for both services. So, again, these first set of codes, physicians, nurse practitioner, physician assistants, that's all who's billing for that. The complexity and the vagueness, which is somewhat frustrating, that is related to, well, who are those other non-physician practitioners, right? So, what did Medicare tell us in their final rule? They said they'd like to reiterate that these services are not for people where this online E&M would fall outside of their scope of benefit category. The specific example that they gave was audiologist and speech-language pathologist. Now, commenters heavily supported and encouraged CMS to give them specific case examples. This is something that I'm going to be monitoring very closely. We really don't have any other clear, concrete guidance as of yet. I was actually even doing some more research this morning. I would see G2061 and G2062 being billable for social workers, in my opinion. but, again, this is something we're going to be watching very carefully. It's a new service that CMS hasn't, unfortunately, come out with too much guidance on just yet. So switching gears a little bit, not necessarily a CPT or a type of code procedure code, but we did get some new ICD-10 codes in 2020 as well for atrial fibrillation, which so many of our patients have. The reason I bring this up is because they're more specific, and in the world of HCC coding, when we're trying to code all conditions to the highest level of specificity, it's important for you to know that there are some new ICD-10 codes. If we go back to the ICD-10 guidelines, they actually explicitly state that you are required to code all conditions to the highest level of specificity that needs to be supported by your documentation. One tool to make you aware of is WHO, which is the World Health Organization, actually owns ICD-10. They're responsible for it, but the CDC has an ICD-10 browser tool, if you just look that up, that will allow you to search for conditions, and it'll tell you the clinical instructional information on appropriate use. I also have used a site called ICD-10 Data. Not being clinical myself, sometimes it's difficult to determine if a particular more specific code would be appropriate based on the documentation, so there are resources out there for you, but if you're not aware of these, and for your patients that have AFib, consider using one of these more specific codes and just be aware of them in 2020. Lastly, I wanted to leave you with a few places that you can get some guidance. First off, you heard me mention earlier the importance of checking with your local MAC, which is your Medicare administrative contractor. If you go on CMS's website, if you're not familiar with it, they have a territory guide and they'll tell you who your MAC is. If you're not sure, you can find it by your state, and if you don't use CMS, they also have a lot of great resources, so their care management page in particular. You can find all the FAQs and fact sheets for CCM, TCM, advanced care planning, behavioral health integration, care management services. This is something I'm going to be watching closely because I anticipate them adding some additional guidance on the services we spoke about today, but they really do have a lot of good resources. Lastly, too, when you're out there, if you are looking for something on the web, I always verify as a coder and an auditor, CPT and the CMS guidelines, if it was changed in the final rule or whatnot, and the NCCI, the National Correct Coding Initiative bundles, but make sure it's through a trusted source because I have been reached out to about, you know, people that have found articles or guidance from one organization or another that might contradict what CMS says. The only valid source, in my opinion, is CMS and CPT when we're talking about our patient population, so just make sure you go to the right place when you're researching these things, and if your practice managers or your coders or your billers are not subscribed to the CMS Listserv or other, you know, trusted coding sources for updates, I subscribe to the OIG as well. That can be a great resource to kind of keep you up-to-date as well. And now I'd like to turn it back over to Danielle to start our virtual office hours. Thank you so much, Brianna, and thank you for sharing your knowledge and expertise and those codes with us. It just looks like that there's so much coming out for 2020, so we really appreciate you taking the time to share that with us. As mentioned before, we're moving into the virtual office hours. We're also joined by Dr. Thomas Cornwell and Dr. Paul Chang, and as we move into these virtual office hours, we're going to submit your questions that were given during the presentation as well as those that we received ahead of time. We have actually had quite a few questions come in, but we want to make sure that we answer all of them. So some of the questions that we have had, let me grab these from in here first. First question is, if a palliative care provider bills for PCM, can primary care providers still bill for CCM? Yeah, that's a great question, and I actually did look at the FAQ that came out for that, and they did say that there would be some circumstances when the care plans are distinctly different and different providers are managing different aspects of the patient's care where that would be possible. What we're going to be doing is we always send out a formal FAQ at the end of these with all the Q&A, and let me pull that guidance and show you exactly what the language says. I would just be very careful. You just need to be very clear with the patients what conditions are you primarily managing, and they understand that they're enrolled in PCM with you and that there's that applicable, very low co-pay, and that the PCP understands you're the lead on that and how their CCM is different. So I wouldn't expect it to be an all-patients scenario, but I could see it being appropriate in some cases, and from the language that I've seen, it does seem like that would be allowed in some circumstances, although I would watch that very carefully. Perfect, and there was a question that it looks like it piggybacked on that. Is the template for CCM for each diagnosis, or can we group them together? That's a good question, too. So the language for CCM says that for those chronic conditions that you're managing, that those severe conditions that are expected to last more than 12 months, they do like to see a disease-specific treatment plan for each condition. So again, if we're talking best practice from an audit standpoint, I would recommend taking the time. It doesn't have to be extensive, but what's your treatment plan for AFib, for COPD, for hypertension? I would list at least some specific condition guidance out separately within that care plan because you do have to have their complete problem list included. Okay. One of our learners has said, I would love to see a visual example of a care plan as discussed with CCM billing, as well as visit note examples used for advanced billing and new codes. Yeah, that's a great question. So one of the resources we do have available on our HCC Intelligence Resource Center is a comprehensive, or the CCM Care Plan Requirements Guideline, where we really lay that out. And I give you all the fields that you could kind of easily create that on your own. However, that being said, you know, I do think having an actual kind of more templated care plan would be a valuable resource, so I'm certainly happy to look into creating that. We do have at HCCI several example cases and patient progress notes, so I'm happy to attach one of those to the FAQs that we could send out to you and see if we can give you some examples for at least one of those advanced coding opportunities. And then certainly, you know, you can reach out to us at any time if we need to talk further about a certain topic or kind of explore how we might be able to best support you. Perfect. And we will make sure that when that FAQ goes out and our question and answers from our presentation today, that we are attaching those additional resources. There's a question and it looks like it's for Dr. Chang, Dr. Cornwell, and Brianna. What screenings are you currently doing for your homebound patients or any key quality metrics your practices focuses on? Paul, you want to take that? Oh, sure. So, we are part of, home care physicians I'm referring to, we are part of a large health system of Northwestern. So the metrics that we are currently collecting is being collected as a group of primary care docs here at Northwestern. So some of the measures include blood pressure control, dilated eye exam, hemoglobin A1c, screening for depression, fall risk, tobacco screening, influenza screening, or vaccination status, and pneumonia shot status. Those are some of the ones that is currently being tracked across the health system here at Northwestern West region. Specifically for homebound patients that we are taking care of, there's nothing that is being monitored on a health system level. But we are internally tracking things such as advanced care planning, such as time to transitional care, follow up, time to first patient visit, if you're a new patient to us. Again, we're trying to service our patient in a timely fashion to keep them out of the costly emergency room and the hospital, and to provide them with care and a resource when they're in need. And the only thing I would add to that is that we do track place of death. We strive if our patients, if it's their wish to enable them to pass away at home. And our health system is kind enough to us that we use a little peer pressure where actually you see how you are compared to all the other doctors, but they have taken us off the list for things like colonoscopy screening, because they know, one, that our patients have a great difficulty doing that. And oftentimes it's not even appropriate to recommend in the condition they're in for them to have such testing. Excellent, thank you so much. A question that came in is, when the situation does not meet the insurance company's definition for medical necessity for a home visit, how should one bill if the visit still occurs in the person's home, or can one not bill for the visit? So that's a good question. Going back to the definition of medical necessity, that's a service that is reasonable and necessary for the treatment of the patient's conditions that are being addressed during that date of service. It's not primarily for convenience, and it meets good standards of medical practice. Now that being said, I do want to make sure that you're aware, as of 2019, there used to have to be additional necessity for why the patient was being seen in the home in lieu of an office visit. That requirement went away as of last year. What CMS came out and said in their final rule is that the justification for a home visit is left to the provider and the patient on the setting that they feel the patient is best cared for as long as the encounter itself is medically necessary. So that doesn't mean that the encounter itself can't be medically necessary, but you do get that additional leeway, that documentation that you probably had a template for in your progress notes is no longer required. Now that doesn't mean that you're typically going to care for everyone, you're still going to care for the population that makes the most sense for you and your organization. Some examples, though, of when I would see medical necessity denials, one kind of red flag would be if you're seeing your patients on the same visit frequency. So if you just across the board are seeing all patients every four weeks, no matter what, that's going to be a big red flag because you should be personalizing the visit frequency to each individual patient's needs. Now keep in mind there are a lot, especially in today's day and age as we're making this transition to value over volume, there are a lot of organizations that choose to set up certain visit frequencies. They might just not bill for a more of a care management check-in or something like that. But generally, if you're going out and you're making a house call, you can make the case for those patients on what you're doing. Again, it just has to paint the picture. What did you really do for that patient on that date of service? Make sure you're taking the time to document all of the work and all of the risks and complexity and all of the things that go into your medical decision making so that that visit is supported. And just don't use a kind of across the board blanketed visit frequency would be my recommendation. And I just want to drive home Brianna's main point is that January 1, 2019, this medical necessity additional requirement for doing a home visit went away. So if a patient needs a blood pressure check, if they need a diabetes visit, Medicare no longer cares if you do it in their home or in the office. You do not need additional reason for doing the home, but they have to have a medical reason such as a blood pressure check. So thank you, Brianna. Yeah, the only thing I would add is that we are not, sorry, we being home-based care providers, medical providers, we are not bound by the same rules that applies to home health agencies regarding home care. That's a good point. So not only do you not have to have additional medical necessity, you definitely don't need to meet the Medicare definition of being homebound. You have to have a medical reason for the visit. Okay. Excellent. We've got a couple more questions coming in. We see all our discharges within seven days. Can we bill high complexity based on that or is it based on MDM? So it's based on both. So yes, if you're within that seven days, that's great, but you also need to meet high medical decision-making, which don't let that scare you away. Look at that MDM table and I can include in the FAQ what goes into MDM. We have a resource on E&M as well, but you do have to have that high medical decision-making in addition to seeing that patient within seven days. Just seeing them that soon is not enough. I think I'm scared away by that high MDM, but there's three areas for the MDM and two of them. One is the amount of data and complexity and if you review labs and you have to talk to someone in addition to the patient, that automatically gets you four points, which is high. And then the other one is the amount of diagnoses and most of our patients have four or more that we're dealing with after a hospitalization and that gets you four points. And so right there, that's two out of three that has that high complexity. And so I'm a little fearful at times of this high complexity, but it really is something that a lot of our hospital follow-ups actually do have. Yeah, just as a reminder, when we look at medical decision-making from an audit standpoint, I'm looking for three things. I'm looking for the number of diagnosis and management options. I'm looking for the amount and complexity of data to be reviewed. And then I'm looking at their overall level of risk. So all of those three things, it's a two out of three mentality, that point system that Dr. Cornwall is talking about. You can find that on any audit tool. If you look at your specific MAC, like NGS's is called their documentation and coding education tool and it lays out that medical decision-making table and how an auditor in their eyes would score that. So again, if you're not familiar with your MACs, they do have some great documentation tools for your specific area. I know First Coast, which is another MAC for sure is over Florida, they actually have an interactive tool where if you're not sure, you can go in and you can kind of play around, that you all have time to do this on a daily basis. But if it may be in a staff meeting, you guys wanted to take the time to fill it out as a team and see what the overall code came out to, that's another great way to kind of look at your accuracy for E&M coding. And my last comment about the fear is that the risk that Brianna talked about, in the risk for high complexity, it has things like acute MI, pulmonary embolus and unstable of pulmonary edema. And so the risk level is quite high, but those other two areas are generally able to meet a significant amount of time. And Paul, you were going to say something, sorry. Yeah, unrelated to the complexity per se, talking about the flexibility within your schedule, this is something you need to work with your staff, your front office, regarding if you have a discharged patient that you need to see, that you want to see within seven days for, whether it's complexity issues or just timely service issues, you may have to bump a patient that's already on the schedule to a different day to be seen, so you can see this patient in an appropriate time. So that's something you need to work out with your staff at the office, so they understand why you are doing this and not just doing this just to torture your staff. Yeah, that's a great point. I mean, you have to have schedule flexibility when you're doing house calls. Don't confirm those appointments too soon, give patients those tentative dates. We actually did a whole different webinar that's available in our archive on geographic scheduling if that's an area you're interested in. We always make our materials available on demand and for download at the result of the webinar. Make sure you have a means of accommodating those transitional care and those acute and urgent visits, whatever that strategy may be for your practice. And just to piggyback on that, there was a question about where these resources are. So if you go to hccinstitute.org, you can actually log into our website and click through either our intelligence link, which will have the archive links for the materials for today as well as past webinars, provide you a connection to our hotline, to our tools and tip sheets, also where you can email in and ask questions. We have our education page, and that talks about our upcoming educational offerings. We have an essential elements of home-based primary care, March 26th and 27th in Schaumburg. We have the advanced applications of home-based primary care, April 16th to 17th. We will also be exhibiting at the AANP National Conference as well as doing a, oh, I'm drawing a total blank. Pre-conference. Thank you. I was like, what is that called? As well as doing a pre-conference there. And then next month, on Wednesday, March 18th, is our medication management webinar, the art of deprescribing medication. So just to kind of put all of those little nuggets out there for you. Another question that came in is, what advanced coding opportunities is Dr. Chang currently utilizing in his practice? Was it difficult to implement these? So currently, I am doing a prolonged services before and after coding for my new patients that I'm seeing for the very first time coming into the practice. There were some challenges with the templates that I had used initially, and an auditor here at Northwestern made some suggestions, and I updated that and sent it in for review, and they said it was fine. So in the template, it talks about, I spent an X amount of time, and in the smart phrase, I documented time from such and such a time to such and such a time in the afternoon on a particular day reviewing the chart related to this patient and the visit. It has to be linked with a particular day of the visit that was made, and it cannot include the time reviewing my own personal notes, but since they're new to the practice, that doesn't really apply. And what I think they wanted to see, the auditor here at Northwestern wanted to see, was more details regarding patient-specific information that you reviewed, and again, our patients are frail, complicated, and usually plenty of stuff that we need to review to make sure they get the appropriate ongoing care that they need. So things that I included in my updated template include a past medical history, make sure you put in relevant patient data, relevant laboratory studies that were reviewed, radiographic imaging that were reviewed. You don't have to state every single chest X-ray that was done in the ICU, but examples of CAT scans or X-rays, pathology results that you reviewed, cardiac studies that you reviewed, include some examples of echocardiogram or EKG. And I think those are some of the, and also list some of the providers that have touched the patient, whether it's a cardiologist, a pulmonologist, an endocrinologist, and so on, include the name and the notes that you reviewed relevant to the visit that you made. Thank you, Dr. Chang. Question came in, for 99358, if you pre-populate your note, how do you bill for it? So you would bill 99358 out on the same claim of the face-to-face visit that it's related to. So it's going to be situational, and depending on your current billing structure and how that works, but you have that non-face-to-face encounter of your start and stop times, your documentation of the work that you did, and then once the face-to-face visit occurs, you bill those services out together, and you just need to work with your billing department or whoever handles that in your practice, your practice manager, maybe you route it to them and they are reviewing your billing anyways or something like that, but you would bill it out together, because you do need to make sure that face-to-face visit happens to bill 99358. All right, and Paul and I have been pretty innovative in terms of Northwestern, because these $80 and even the $12.25 INRs, they accumulate, and so we really kind of push the system with these new codes, and oftentimes communicate with them just to make sure that we're doing everything right. And you heard Paul was told when he showed them what he was doing, how they thought we could do it better, and I actually found out I was doing something wrong too, and I think this is what the question was asking, is obviously if you pre-populate your note, when you see the patient and you change that note, how does Medicare know what you did pre-visit? And so what I found out, because I was, what I would do is I would pre-populate my note, but then I would cut it and paste into a telephone note, so I had that separate, so it would never change, so we have that document of what I did before the visit. What I found is that in Epic, and this is what Paul was doing, there is a non-face-to-face document note that you can create, and then actually bill in that, and so what I would do is I'd pre-populate my note for the visit, I would cut that information I did pre-seeing the patient into this non-face-to-face document, so again, that there was a clear picture of what I did before the visit, and then when I ended up changing, you know, and adding to the history during the visit, Medicare, if they ever audit it, can see the difference between what was done before the visit and what was done during the visit. I hope that answers the question. Yeah, there's none, that's a good point too, so with any EHRs, you're going to have like a charge capture option, and typically you can still do that from non-progress note encounters, you just need to, again, work with your EMR and your billing software, depending on what you're using and how you do that. Excellent, thank you, and then the last one is kind of a question comment. This individual is a startup for a house call and telemedicine practice, and it looks like they're kind of asking what are some of the best codes to use to begin that, or common codes that they will use when doing that. Well, congratulations, and thank you for your interest in home-based primary care. We're excited to see new practitioners out there doing this, and please know that HCCI is here for you as a resource, but definitely make sure you're familiar with the home visit codes and the domiciliary codes, the E&M codes that you're going to use for assisted living and group home settings, and then think about, you know, these care management opportunities, whether it may be a CCM is right for you, or you mentioned telehealth, these technology-based services, we didn't talk about them today, but the virtual check-in, there's a G-code G2012, which could be even just a telephone call of a minimum of five minutes, look into remote patient monitoring if that's something that you're going to do. Again, the reimbursement is still pretty limited, but it does add up, so just make sure you know what services are bundled together, and then, you know, in this field, in home-based primary care and home-based palliative care in general, you're doing so much care management and non-face-to-face work with your patients, so just make sure you find the right opportunity that aligns with what you're doing so you can get paid for that. Excellent. Dr. Cheng, Dr. Cornwell, anything to offer for someone that's starting out? Yeah, I think working with your – this gets into EHR and working with your coder and builder. With our EPIC, and at the end of the visit, there's a place where you can click a pre-populated visit code, so you don't have to have a cheat sheet or try to memorize all these codes in your head. You can actually just go, and as you're finishing the note, click on that particular visit code, including some other management services you might be using. We have a favorite button, such as before and after visit. There's a button I can use for that or a button I use for anticoagulation management or joint injection or so forth, so that this – having a pre-populated field can really reduce the amount of stress and documentation that's necessary to capture or to get appropriately paid for the work that you're doing. Right, and what I have to offer is Breanna, and that was what came to my head when you said, what does Dr. Cornwell have to offer? I have Breanna, and we do have a free hotline here that Breanna answers the calls, and it's a free service, and so she is just – I mean, I'm just – in fact, I sent her, I thought, a question that would stump her, and I did not stump her. And so, I'm very proud of her, and she is a great resource for anyone on the line in terms of if you have specific questions, she either has the answer or will find the answer for you. Well, thank you. I get – like I said, I mean, any provider and any practice staff that works in this field are just some of the most amazing people that are privileged to have in our patients' and caregivers' life, and, you know, we're fortunate to work at HCCI. That's such a mission-driven organization where I can have the opportunity to support people like you on this call, so thank you, everyone. And I think that is a great segue, as we have about a minute left. I want to thank all of our presenters, Brianna and Dr. Cornwell and Dr. Chang, for their time during our virtual office hours and for answering all of your questions, and all of you for attending and sharing such great questions with us. I do see one more final question. We will not have time to answer it today, but we'll make sure that we definitely address the question of any update on EPIC assisting with scheduling. We'll make sure that question goes into our Q&A, and again, thank you all for joining us. We'll be sending up a follow-up email within the next probably five days or so. It will have a link to the archive recording, the Q&A, any handouts that would be associated with this, and then a copy of the presentation itself. Remember to please visit the HCCI website for information on future webinars, e-learning modules, learning events, consulting services, and other resources that we offer. Thank you to everyone for joining us, and have a wonderful evening. Thanks everyone. Thank you. Thanks.
Video Summary
In this webinar, Brianna Plentsner discusses the coding updates for 2020. She covers topics such as chronic care management, transitional care management, online digital E&M services, and new ICD-10 codes for atrial fibrillation. She provides information on the requirements and reimbursement rates for each of these services. Brianna also mentions the importance of checking with local Medicare administrative contractors for any new guidance on these services. She recommends using certified EHRs and developing templates for care plans to ensure compliance. Brianna emphasizes the need for proper documentation and coding to support the services provided. During the virtual office hours portion, Dr. Thomas Cornwell and Dr. Paul Chang join the webinar to answer questions. They discuss the screenings and quality metrics used in their practices, as well as the challenges and opportunities of implementing advanced coding. Overall, the webinar provides an overview of the coding updates for 2020 and offers guidance on implementing the new codes in practice.
Keywords
webinar
coding updates
2020
chronic care management
transitional care management
ICD-10 codes
reimbursement rates
Medicare administrative contractors
certified EHRs
documentation
©2022 Home Centered Care Institute. All rights reserved.
×
Please select your language
1
English