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Friday, June 24, 2016

Make sure to recertify EIDM users by June 30

Time is running out if your practice hasn’t recertified its user accounts in the Enterprise Identity Management (EIDM) system. Letting those accounts lapse could complicate reviewing your Quality and Resource Use Reports (QRURs) later.

Individual practitioners and providers’ security officials (SOs) have until June 30 to log into the system and recertify who in the practice has the right to access the system. The Centers for Medicare & Medicaid Services (CMS) requires users to recertify annually. Failure to recertify user roles will result in those roles being revoked. Once revoked, the user must go through the process of requesting the role from the SO or individual practitioner again.

The SO and individual practitioners can log into the CMS Enterprise Portal using existing credentials and access the list of users who require recertification. The list is located under the “View and Manage Access” page under the “Annual Certification” link on the left-hand side of the screen. If you experience issues, you can contact the QualityNet Help Desk at 1-866-288-8912. The QualityNet Help Desk can also tell you who the SOs are for your Tax Identification Number (TIN).

Maintaining access to the EIDM system is critical for the QRUR. CMS releases a mid-year QRUR and an annual QRUR. The 2015 mid-year reports were released in April, while the 2015 annual reports will be available in the fall. These reports provide information on a TIN’s performance on cost and quality measures. Practices can use the QRUR to review their performance and identify areas where improvement may be needed. Reviewing today will help practices prepare for the implantation of the Medicare Access and CHIP Reauthorization Act (MACRA).

– Erin Solis is the Regulatory Compliance Strategist at the American Academy of Family Physicians

Thursday, June 23, 2016

How much can you charge patients for their health information?

The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services recently addressed patients’ rights to access their protected health information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Much of the guidance focuses on the fees that a covered entity, such as your practice, may charge patients requesting copies of their own PHI.

According to OCR, you can charge patients for:

1.    labor costs (including preparation of an explanation or summary when agreed to by the individual)
2.    supply costs related to the creation of either the electronic or paper copy (e.g., paper, toner, CD, or USB drive)
3.    postage costs when the individual requests the information be mailed

The OCR guidance indicates that permissible labor costs may include only the labor “for creating and delivering the electronic or paper copy in the form and format requested or agreed upon by the individual, once the PHI that is responsive to the request has been identified, retrieved, or collected, compiled and/or collated, and is ready to be copied.” (Emphasis added) That means you cannot charge for reviewing the request or searching for and retrieving the information.

The OCR also emphasizes that you may not charge individuals for system maintenance, data storage and maintenance, or the administrative costs associated with outsourcing your office’s response to requests for PHI. OCR further notes that if you use systems that allow individuals to access their PHI through electronic health record technology, you may not charge labor or supply costs.

The OCR guidance says that when calculating the fees you charge, they may reflect your actual costs, your average costs, or a flat fee. If using actual costs, they must be reasonable and calculated upon each request. OCR says that you can charge average costs as a standard rate (e.g., a per-page fee if you maintain the requested PHI in paper form and the individual requests a paper copy). The OCR adds that “per page fees are not permitted for paper or electronic copies of PHI maintained electronically.” Finally, you can charge a flat fee but only for electronic copies of electronically maintained PHI, and the flat fee cannot exceed $6.50.

Regardless of the fee method used, you must notify individuals in advance of any fees that could be charged for their requests for PHI at the time the details of the request are being arranged. Failure to provide such notice could potentially be a HIPAA violation.

If a patient requests that you send their PHI to a third party, you must treat that request the same under HIPAA as if the patient were requesting it be sent to them directly. However, if a third party initiates the request for PHI, the limitations on copying fees do not apply. So, you should ask whether the request was a direction from the patient or a request from a third party.

Finally, the OCR guidance discusses the relationship between HIPAA and state law. Specifically, when it comes to an individual's right to access his or her own PHI, HIPAA trumps state law if HIPAA provides individuals with greater access to their PHI. That means if your state law allows you to charge higher fees or to limit an individual’s access, HIPAA will preempt that state law.

Needless to say, now may be a good time to review your policies and procedures for granting access to individuals’ PHI, including whether and how you charge for copies of that information.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, May 31, 2016

CMS releases list of approved 2016 PQRS registry vendors

The Centers for Medicare & Medicaid Services (CMS) has released the 2016 lists of approved Qualified Registries and Qualified Clinical Data Registries for the Physician Quality Reporting System (PQRS). Physicians and group practices may use these third-party vendors to submit quality measures for PQRS in 2016 and potentially avoid payment penalties associated with PQRS and the Medicare value-based payment modifier in 2018.

There are a number of other PQRS reporting options. For those new to the program, the AAFP provides a PQRS overview, and CMS has instructions on how to get started.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, May 17, 2016

Small practices face potential headaches under MACRA

For solo and small physician practices, the recently published proposed rule for how the Centers for Medicare & Medicaid Services (CMS) plans to implement the Medicare and Children’s Health Insurance Program Reauthorization Act (MACRA) set off some alarm bells. According to the proposed rule’s regulatory impact analysis, 87 percent of solo practice clinicians who are eligible for the Merit-Based Incentive Payment System (MIPS) – one of two payment tracks under MACRA – will receive a penalty; for groups of two to nine clinicians, the percentage is almost 70 percent.

Responding to the concerns generated by this analysis, CMS has now issued a fact sheet that attempts to show it is sensitive to the unique challenges that small practices face in different types of communities. The fact sheet is also meant to show that the agency’s proposed implementation of MACRA, including MIPS and alternative payment models (APMs), provides accommodations for various practice sizes and configurations. Among the provisions that CMS highlights in its defense are:

• Clinicians or groups that have $10,000 or less in Medicare charges and 100 Medicare patients or fewer are excluded from the MIPS payment adjustment.
• When a practice is scored for MIPS, it will only be scored for categories where it has a sufficient number of applicable measures and activities.
• Small groups will have more flexibility within each of the MIPS performance categories. For example, CMS will calculate only two population measures based on claims data for solo physicians and groups of nine or fewer physicians instead of the three population measures required for larger groups under the quality performance category of MIPS.

CMS also notes that the proposed rule allows small practices or practices in rural or healthcare professional shortage areas to participate in the Advanced APM track – and receive incentive payments – by providing special rules for these practices to qualify as Advanced APMs under medical home models.  

Ironically, CMS plans to delay implementing one provision of MACRA specifically intended to help solo and small group practices succeed under MIPS. Specifically, MACRA allows MIPS-eligible professionals to combine into “virtual” groups to participate in the payment track. However, as noted in the fact sheet and the proposed rule, CMS will not make this option available until the second year of the program.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, May 13, 2016

Medicare physician use and payment data for 2014 now available

The Centers for Medicare & Medicaid Services (CMS) has released its annual report on Medicare physician utilization and payment data.

Covering calendar year 2014, the public file lists Medicare Part B payments and submitted charges for more than 986,000 individual physicians and other health care providers who collectively received around $91 billion. By comparison, the report for 2013 included $90 billion in payments to 950,000 physicians and other providers.  

The latest report uses Medicare standardized payment amounts, which adjusts for geographic differences to make payments to physicians in different parts of the country comparable.

As we’ve discussed in the past, these annual payment reports show not only the range and complexity of care that family physicians provide but also the variation in reimbursement among medical specialists. For example, family physicians received an average of $61,804 in total Medicare payments during 2014. By comparison, internists received an average of $92,760 and cardiologists received an average of $222,373. As in the past, physicians weren't given an opportunity to review the information tied to their names for errors and the amounts don't reflect risk-adjustment, Medicare not covering the full cost of certain treatments, or other factors.

As CMS moves to tie physician reimbursement more closely to value, presenting accurate individual physician payment and utilization data to patients and other interested parties will become more critical.

Thursday, May 12, 2016

Some help understanding the proposed MACRA payment reforms

Last month, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that describes how CMS intends to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA repealed the Medicare sustainable growth rate methodology with a new approach that pays clinicians for the value and quality of care they provide. The proposed rule would implement these changes through a unified framework called the “Quality Payment Program,” which includes two paths – the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). Comments on the proposed rule are due to CMS by June 27.

In the regulation, CMS says it expects that most Medicare physicians will initially participate through the MIPS. The MIPS consolidates three existing programs, the Physician Quality Reporting System, the Physician Value-based Payment Modifier, and the Medicare Electronic Health Record (EHR) Incentive Program. MIPS will pay Medicare physicians for providing high value care through success in four performance categories:

•  Quality (50 percent of total score in year one): For this category, physicians would choose to report six measures from among a range of options.
•  Advancing Care Information (25 percent of total score in year one): For this category, physicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting. CMS created a summary specific to the Advancing Care Information category.
•  Clinical Practice Improvement Activities (15 percent of total score in year one): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Physicians may select activities that match their practices’ goals from a list of more than 90 options.
•    Resource Use (10 percent of total score in year one): For this category, the score would be based on Medicare claims, meaning no reporting requirements for physicians. This category would use 40 episode-specific measures to account for differences among specialties.

CMS would begin measuring performance for physicians and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019.

Under the APM pathway, MACRA authorizes incentives for physicians who take further steps towards care transformation. To qualify as an Advanced APM, an APM must 1) require participants to use certified EHR technology, 2) pay covered professional services based on quality measures comparable to those in the quality performance category under MIPS, and 3) mandate that participating APM entities bear risk for monetary losses of a more than nominal amount – or that the entity must assume risk for potential financial losses – under the APM. CMS proposes three dimensions of risk – marginal risk, minimum loss rate, and total potential risk – to determine if an entity meets the more than nominal risk standard. Medicare physicians who sufficiently participate in an Advance APM would be exempt from MIPS reporting requirements and qualify for a 5 percent Medicare Part B incentive payment.

CMS notes that physicians who participate to some extent in APMs may not meet the law’s requirements for sufficient participation in the most advanced models. But it says the proposed rule is designed to provide these clinicians with financial rewards within MIPS. CMS expects that the number of clinicians who qualify as participating in Advanced APMs will grow as the program matures.

As an alternative to reading the more than 900 pages of regulations, the CMS issued a press release and the Health and Human Services secretary published a blog post, which includes the video, “Delivery System Reform: Paying for What Works.”

Keep an eye on this space for additional information on MACRA as we more fully understand how this law will affect family physicians for years to come.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Thursday, April 21, 2016

Medicare keeping vigilant on observation services

If you or your practice provides observation care at a local hospital to Medicare patients, the Centers for Medicare & Medicaid Services (CMS) is issuing a gentle reminder to pay attention to your documentation for those services – if you don’t want to face a refund request.

In the latest issue of CMS’s Medicare Quarterly Provider Compliance Newsletter, the agency indicates it is keeping a close eye on physician billing for hospital observation services. In the article, “Comprehensive Error Rate Testing (CERT): Observation Services,” CMS notes that evaluation and management (E/M) services, such as observation services, remain a leading cause of improper Medicare payments. CMS also notes that most improper payments were due to insufficient documentation, such as:

•    No order for observation services
•    No progress notes
•    No physician’s signature on a progress note

As an example, CMS describes the case of a physician who billed Medicare for CPT 99217 (“Observation care discharge”) for a date of service in April 2013. However, the submitted documentation was missing signed and dated physician’s orders for observation services and was also missing a signed and dated progress note to support a face-to-face encounter on the date of service. The physician was unable to produce any documentation to support that he or another member of his group had seen the patient on the date of discharge from observation. Subsequently, the Medicare administrative contractor recovered the payment.

The article also reminds physicians that even when documentation is present, it must support the level of E/M observation service claimed. Failure to document the level of service claimed also constitutes a potential overpayment as far as Medicare is concerned.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, April 13, 2016

CMS provides details on Comprehensive Primary Care Plus

Like an auto company touting the latest model or a certain soda manufacturer unveiling its “new” version of an old “classic,” the Centers for Medicare & Medicaid Services (CMS) has revealed its latest effort to transform and improve how primary care is delivered and paid for in the United States. CMS will implement the Comprehensive Primary Care Plus (CPC+) model in up to 20 regions of the country, accommodating up to 5,000 practices and more than 20,000 physicians and other clinicians. It would also seek to encompass up to 25 million patients.

Building on the Comprehensive Primary Care initiative launched in late 2012, which is already being dubbed “CPC Classic,” the five-year CPC+ model will offer primary care practices two tracks for participation. Both tracks will require practices to:

•    Support patients with serious or chronic diseases to achieve their health goals
•    Give patients 24-hour access to care and health information
•    Deliver preventive care
•    Engage patients and their families in their own care
•    Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

Practices in Track 2 will also be expected to provide more comprehensive services for patients with complex medical and behavioral health needs, including, as appropriate, a systematic assessment of their psychosocial needs and an inventory of resources and supports to meet those needs.

Physicians participating in CPC+ will receive monthly care management fees for eligible beneficiaries in their practice. Physicians in Track 1 will be paid depending on where each patient falls across four risk tiers, with an average of $15 per beneficiary per month. In Track 2, physicians will be paid according to five risk tiers, with an average of $28 per beneficiary per month, including $100 per month for the most complex patients. Practices can use these fees for increased staffing and training necessary to meet the model’s patient care requirements.

In addition to the care management fees, Track 1 physicians will continue to receive their normal Medicare fee-for-service payments. Physicians in Track 2 will receive a new hybrid of fee-for-service payments and a “Comprehensive Primary Care Payment,” which will include a percentage of the expected Medicare reimbursement for Evaluation & Management (E/M) claims upfront. Reimbursement for the E/M claims themselves will be reduced.

In addition to these payments, CMS will award practices incentives based on performance.

Like CPC Classic, Medicare will partner under the CPC+ model with commercial and state health insurance plans. CMS will accept proposals from payers wanting to partner in CPC+ between April 15 through June 1, selecting regions of the country that reflect sufficient interest from multiple payers. Practices in the selected regions can apply to participate from July 15 through Sept. 1.

CMS is offering additional information on CPC+ through a press release, a fact sheet, and frequently asked questions.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, April 8, 2016

Open Payments review and dispute period ends May 15

Physicians and teaching hospitals have until May 15 to review financial information reported about them under the “Open Payments” system and dispute information they believe is incorrect before the information is released to the public on June 30.

The Centers for Medicare & Medicaid Services (CMS) annually asks pharmaceutical and medical device manufacturers and group purchasing organizations to report all payments or other transfers of value they made to physicians and teaching hospitals during the previous year. The June 30 release includes information for 2015, along with updates to the databases for 2013 and 2014.

The review process is voluntary, but to participate and file disputes, you will need to register in both the CMS Enterprise Identity Management System (EIDM) and the Open Payments system itself.

If you registered last year, you don’t have to register again. Go to the CMS Enterprise Portal, log in using your user ID and password, and navigate to the Open Payments system home page. If you haven’t accessed your account in the last 60 days, you will need to answer some challenge questions and then reset your password. If you haven’t visited in more than 180 days, you’ll have to contact openpayments@cms.hhs.gov to reinstate your account.

Thursday, April 7, 2016

CMS releases 2015 mid-year Quality and Resource Use Reports

The Centers for Medicare & Medicaid Services (CMS) has released the mid-year Quality and Resource Use Reports (QRURs) for 2015. These reports are released annually and serve as a tool for physicians to review their performance on a subset of measures that will be used to calculate the 2017 Value-Based Payment Modifier (VBPM).

The mid-year QRURs are for informational purposes only and cover the performance period between July 1, 2014, and June 30, 2015. This performance period differs from the actual performance period that will be used to calculate the 2017 VBPM. The reports contain data on six cost measures and three claims-based quality outcome measures.

While the performance information included on the mid-year QRUR may differ from the 2015 QRUR, which comes out in the fall, the report still offers physicians a good opportunity to review their performance and implement quality improvement activities for the upcoming year. A physician’s performance in 2016 will be used to calculate his or her 2018 VBPM.  

CMS has created resources on how to use your 2015 mid-year QRUR as well as how to obtain the report.

-- Erin Solis is the regulatory compliance strategist for the American Academy of Family Physicians

Wednesday, April 6, 2016

Groups can now register for the 2018 PQRS

Physician practices wanting to use the Group Practice Reporting Option (GPRO) to participate in the 2018 Physician Quality Reporting System (PQRS) have until June 30 to register. If not, all providers within the group must report to PQRS as individuals or face a Medicare pay penalty in 2018.

The Centers for Medicare & Medicaid Services (CMS) defines a “group” as a single Tax Identification Number (TIN) with two or more individual providers with National Provider Identifiers (NPIs) who have reassigned billing rights to the TIN. Groups can register using an Enterprise Identity Management (EIDM) account. CMS encourages users to create or modify existing EIDM accounts now to avoid delays. If you are unsure if someone in your group is already enrolled with the EIDM system, contact the QualityNet Help Desk. You will need the group’s TIN and name.

During registration, you will select your reporting method. Your choices are:
•    Qualified PQRS Registry
•    Electronic Health Record (EHR)
•    Qualified Clinical Data Registry (QCDR)
•    Web Interface (for groups with more than 25 providers)

Physicians wanting to report using the EHR or QCDR methods will need to be sure that their vendors meet the requirements for group reporting. Additionally, groups with between two and 99 eligible professionals (EPs) will need to decide if they want to supplement their reporting with the Consumer Assessment of Health Care Providers and Systems (CAHPS) for the PQRS survey. CAHPS is required for groups with 100 or more EPs.

All groups and solo physicians will be subject to the 2018 Value Modifier. Participation in the PQRS program will help you avoid the automatic downward payment adjustment for failure to satisfactorily report.

--Erin Solis is the regulatory compliance strategist for the American Academy of Family Physicians

Tuesday, April 5, 2016

Compensation for family physicians rises in new survey

Family physicians saw their average overall compensation increase last year, and they felt slightly less anxious about their pay and their profession, according to a new report.

The Medscape Physician Compensation Report 2016, released April 1, reported that family physicians made an average of $207,000 in total compensation in 2015, up 6 percent from the previous year. Most specialties saw gains in annual compensation, with the highest-paid physicians being orthopedists with an average of $443,000. The lowest-paid specialty was pediatrics with an average of $204,000.

In addition to receiving higher pay, 52 percent of all physicians (and 52 percent of family physicians) said they believed their compensation was fair. By comparison, half of all physicians and 48 percent of family physicians felt they were fairly compensated in 2014. Dermatologists (66 percent) felt the most comfort with their compensation, while urologists (42 percent) were the least satisfied. Among family physicians, 73 percent said they would still choose medicine as a career if they had to do it all over again, which is up from 69 percent five years ago. The percentage of family physicians who would stick with the specialty, however, has fallen from 44 percent in 2011 to 29 percent now.

The trend of physicians choosing to work for hospitals and other large health care groups appeared to remain steady with 35 percent of men and 23 percent of women sticking with private practice, virtually the same percentages as a year ago.

Male and female compensation continued to have a disparity, but it is shrinking. Male family physicians made an average of $220,000 versus $183,000 for female family physicians, a difference of 20 percent. The difference was 28 percent in 2011. Also, survey results showed that female physicians faced a similarly sized pay gap regardless of whether they were employed or self-employed.

Despite the continued focus on “direct primary,” “concierge,” or “direct pay” care models, those types of practices remain very much in the minority. Only 10 percent of family physicians reported being in a concierge or cash-only practice, the same amounts as in 2014. The researchers said it appeared private practice physicians looking to get away from the regulatory and financial headaches of traditional practice are more likely to go into employed positions rather than go the direct-pay route.

The survey also said 39 percent of family physicians were in an accountable care organization (ACO) and 7 percent planned to join one in the coming year. By comparison, 35 percent belonged to one in 2014 and 8 percent planned to join one.

Thursday, March 31, 2016

CMS answers questions about chronic care management

On March 17, the Centers for Medicare & Medicaid Services (CMS) answered some common questions about chronic care management (CCM) services. Among the highlights:

•    CMS states that if a skilled nursing facility, nursing facility, or assisted living facility meets all the CCM billing requirements and it is not receiving payment for care management services, you may bill CPT 99490 for CCM services furnished to beneficiaries there. The place of service on the claim should be the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient).

•    CMS specifies that levels 2 through 5 evaluation and management (E/M) visits qualify as “comprehensive” visits for CCM initiation. CMS is not requiring the practice to initiate CCM during a level 4 or 5 E/M visit. However, CPT codes that do not involve a face-to-face visit by the billing practitioner or are not separately payable by Medicare do not meet the requirement for the visit that must occur before CCM services are furnished.

•    CMS indicates that it will give the billing practice some latitude in situations where the billing practice has the ability to send clinical summaries or the electronic care plan by way of an acceptable electronic technology other than fax, but the receiving practice/provider (which is not billing for CCM services) can only receive the required information by way of  fax.

For additional information, a fact sheet on CCM is available on the CMS website. The agency also notes that the scope of service elements and other requirements for billing CCM to the Medicare physician fee schedule (MPFS) are laid out in the calendar year 2014 and 2015 MPFS final rules (CMS-1600-FC, CMS-1612-FC and CMS-1612-F2), which are also available on the CMS web site.

– Kent Moore, senior strategist for physician payment for the American Academy of Family Physicians

Wednesday, March 30, 2016

MGMA-AMA encourage collaboration to solve health care challenges

Almost 350 physicians, practice administrators, and other health care leaders met in Colorado Springs, Colo., March 20-22 for the inaugural Collaborate in Practice Conference, sponsored by the Medical Group Management Association (MGMA) and the American Medical Association.

The event was billed as a way to help practices better handle the many challenges facing medicine through better teamwork, leadership, and collaboration among physicians, other clinicians, managers, and other partners.

Halee Fischer-Wright, MD, president and CEO of MGMA, said that health care can’t just confront change but needs to control it or, better yet, lead the way.

Breakout sessions focused on such topics as making team meetings more effective, refining and reinforcing your practice’s culture, finding ways to give patients more access so they don’t gravitate to other providers, and increasing physician engagement to fend off burnout.

Some takeaways from the sessions:

• 71 percent of malpractice suits are tied to miscommunication and poor physician-patient relationships. Practices should focus on fighting dysfunction within teams, defusing toxic relationships that can affect patient care, and create the kind of supportive environment where patients are more likely to share their own personal or social issues that could influence treatment. – Monica Broome, MD

• All team meetings should have a specific purpose and goal. Meetings are a vital sign for your organization, and useless or unsuccessful meetings may reflect a structural problem within the practice. – Steven Bromer, MD

• Practice administrators or physician leaders will have more success changing clinician behavior by appealing to their mastery, autonomy, and sense of purpose. Framing a change simply as a response to regulatory requirements is not helpful. – Stephen Beeson, MD

• To increase patient satisfaction, have nurses call patients the day after a visit, which can either make a satisfied patient even happier or give a dissatisfied patient a chance to complain before it becomes more work for the practice; take advantage of the perceived connection between cleanliness and good care by keeping your office clean; make sure the receptionist always makes eye contact with the patient upon entering; and try to give patients the appointment times they want so you don’t run the risk of the patient showing up late and throwing off your entire schedule. – William Faber, MD

• Leaders should not feel the need to be perfect in all facets of leadership. Instead, they should lead with their strengths, such as execution or motivation, and rely on their team to make up for their weaknesses. – Wayne Guerra, MD

• When done correctly, incorporating health care information technology into your practice can improve patient engagement, physician workflow, and, ultimately, physician happiness. Introduce technology innovations slowly, aim for short-term gains, but ultimately lay the groundwork for big wins down the road. – Lyle Berkowitz, MD

Monday, March 28, 2016

CMS answers billing questions on advance care planning

Medicare began paying for advance care planning services on Jan. 1. As with most new reimbursement programs released by the Centers for Medicare & Medicaid Services (CMS), physicians have had questions. Last week, CMS attempted to answer some of them.

Advance care planning services are described by two Current Procedural Terminology (CPT) codes:

•    99497, Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
•    +99498, Each additional 30 minutes (List separately in addition to code for primary procedure).

Among the highlights in the CMS’s answers:

•    CMS will follow CPT provisions regarding minimum time required to report the service; that means a unit of time is attained when the mid-point is passed.
•    CMS has not established any frequency limits for these services.
•    There are no place of service or physician specialty limitations on the codes.
•    Medicare administrative contractors will determine any documentation requirements.
•    Completion of an advance directive is not required to bill the service.
•    Advance care planning can be reported in addition to other evaluation and management services, except certain critical care services.
•    No specific diagnosis code is required with advance care planning codes.
•    These services are subject to the usual Part B deductible and coinsurance unless furnished as an optional element of the Medicare annual wellness visit.

For additional information, CMS encourages you to read pages 70955-70959 of the final rule on the 2016 Medicare physician fee schedule and Medicare Learning Network Matters article MM9271.

– Kent Moore, senior strategist for physician payment for the American Academy of Family Physicians

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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