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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

Thursday, March 17, 2016

Fee-for-service still dominant force in reimbursement

Federal officials want to move quickly to transition Medicare reimbursement away from models based solely on volume of services.

A new study demonstrates how far they need to go.

In results published in Health Affairs, the study found that only 5 percent of patient office visits in 2013 were paid based on capitation arrangements and the remaining 95 percent were all some form of fee-for-service.

The researchers, using data mined from the annual Medical Expenditure Panel Survey, noted that capitation, which sought to shift some or all of the financial risk for providing patient care to physicians, has seen a steady decline in acceptance since its inception in the 1990s and especially during the 2000s.

New models, such as those detailed in the Medicare Access and CHIP Reauthorization Act of 2015, are designed to reward physicians based on value and quality of patient care. Supporters believe value-based care is less expensive and could reduce the number of unnecessary tests, procedures, and other services that can go unchecked under fee-for-service. However, many physicians worry that attempts to measure value and quality will be cumbersome and ineffective, and could penalize them unfairly.

The researchers suggested that physicians may be more willing to embrace value-based care than they were to embrace capitation, but they acknowledged physicians' reluctance. “Providers’ willingness to participate in new payment mechanisms will likely be closely tied to the extent that they are required to assume risk,” the study said.

Largely because of this, fee-for-service remains a key mechanism for paying physicians even within organizations set up to emphasize value, such as accountable care organizations.

Thursday, March 10, 2016

Study: Practices spend $15.4 billion a year to measure quality

Physicians often complain about the time they have to spend filling out documentation and other forms to report quality measure information.

A new study published in Health Affairs attempted to quantify the problem and found that practices in primary care and three other common specialties spend an average of 785 hours per physician annually on entering quality information into computers, reviewing quality reports generated by external entities, tracking quality measure specifications, implementing processes for collecting data, and transmitting that information to third parties for quality measurement.

Multiplied by the average compensation for each type of physician and staff member, the study estimated U.S. practices spend more than $15.4 billion a year to report these quality measures.

Of the four specialties – which included primary care (family medicine and internal medicine), cardiology, orthopedics, and multispecialty practices that included primary care – the primary care physicians spent the most time and money on quality measures.

The study said those practices spent an average of 19.1 hours per physician per week on quality measurement with the physicians alone spending 3.9 hours. Annually, those practices spent an average of $50,468 per physician.

By comparison, cardiology practices said they spent 10.4 hours a week (1.7 hours for physician only) and $34,924 a year while orthopedic practices said they spent 11.3 hours a week (1.1 hours for physician) and $31,471 a year.

Multispecialty practices said they spent 17.6 hours a week. Researchers did not include financial information for multispecialty practices because the practices include specialties outside the study’s scope.

The study, paid for by The Physicians Foundation, was based on surveys of more than 300 practices contacted through the Medical Group Management Association database.

Researchers said 81 percent of respondents reported spending more time and money meeting quality measurement requirements now than three years ago and only 27 percent said they believed the measures actually represented quality care.

In addition, the report found that federal programs, state and regional agencies, and health insurers often use hundreds of quality measures that share very little in common with one another, compounding the work practices must perform to comply with all their requirements.

“There is much to gain from quality measurement,” the study authors write, "but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures.”

Wednesday, March 9, 2016

Majority of physician groups see no change under Value Modifier program

The Centers for Medicare & Medicaid Services (CMS) has released the results of the 2016 Value Modifier (VM). The VM lowers or raises a physician’s Medicare payments based on his or her performance on quality and cost measures. The 2016 results, which apply to physician groups of 10 or more eligible professionals (EPs), are based on data reported in 2014.

Of the 13,813 physician groups with 10 or more EPs, only 128 groups exceeded the program’s quality and cost benchmarks. These groups will receive an increase of either 15.92 percent or 31.84 percent in their payments under the Medicare Physician Fee Schedule. Physicians in 59 groups will see their payments reduced by 1 percent or 2 percent based on their performance on quality and cost measures. There were 5,418 groups who failed to meet the reporting requirements and will face an automatic 2 percent cut. The remaining 8,208 groups will not face any adjustment because of their performance or because there was insufficient data to calculate their VM.

Medicare Administrative Contractors will process claims based on the updated adjustment amounts beginning March 14. Claims with a date of service prior to this will automatically be reprocessed. Groups should see the adjustments on their claims within the next six weeks.

Beginning in 2017, the VM will apply to solo physicians as well as those in groups of two or more physicians. To avoid an automatic payment decrease, physicians should report to the Physician Quality Reporting System (PQRS). Physicians can pull their annual Quality Resource and Use Report (QRUR) to review their performance on quality and cost measures and see how they will fare under the VM.

--Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

Monday, March 7, 2016

Medicare contractor clarifies "incident-to" rules for allergy therapy

Medicare’s “incident-to” rules become less mysterious the more you learn about them. But that doesn’t mean physicians and practice administrators aren’t still sometimes baffled by how they work.

Earlier this year at a forum, Wisconsin Physician Services (WPS), a Medicare administrative contractor, answered a question about providing allergy therapy that surprised many. In essence, the question was: If a nurse in the practice administers allergy injections to a patient, can the practice bill the service under the physician's Medicare provider number, even though the physician is not treating the allergy?

In its response, WPS referenced Medicare Learning Network Matters article Special Edition (SE) 0441, which addresses incident-to rules. WPS noted that one of the requirements of incident-to billing is that the billing physician is the one treating the patient for that condition or situation. So, if the physician in question is treating the patient for the allergy (not just providing the injections), then this situation could meet the incident-to requirements.

If the physician is not treating the patient for the allergy, then, according to WPS, this situation does not meet the incident-to requirements, and the physician cannot bill for the administration of the injection. WPS advises notifying the patient of non-coverage in this scenario.

Even if this particular situation wasn’t on your radar, it should show that incident-to rules are definitely being scrutinized by Medicare administrative contractors.

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

Thursday, March 3, 2016

You’ve made the switch to ICD-10 coding. Now what?

It’s been more than five months since ICD-10 became the required standard for coding and billing patient encounters in the United States, and the Centers for Medicare & Medicaid Services (CMS) wants to make sure your office is using ICD-10 not just correctly but productively. CMS has released the Next Steps Toolkit, a free resource that offers specific suggestions and recommendations in these areas:

Assessing your progress. Practices should compare current performance to a pre-ICD-10 baseline or establish a baseline for making future comparisons. Tracking key performance indicators such as rates of rejection and denial is the first step to improvement.

Addressing your findings. Systematically collecting and answering questions from staff and analyzing your clinical documentation and code selection as needed can help head off future problems and fix current ones.

Maintaining your progress. Physicians should make sure their systems capture annual ICD-10 updates, which take place in October.

For more information, visit CMS’s ICD-10 website and other resources, including this list of contacts, by state, for Medicare and Medicaid questions. 

Tuesday, March 1, 2016

Deadline for meaningful use hardship exception extended

The Centers for Medicare & Medicaid Services (CMS) has extended the deadline for physicians and other providers to submit hardship exceptions for the meaningful use (MU) program. Providers now have until July 1 to apply for an MU exception. An exception would allow them to avoid the 2017 payment adjustment for failure to meet the reporting requirements in 2015. The previous deadline was March 15. CMS encourages providers to submit their applications electronically as soon as possible to avoid delays.

Applying for and receiving an exception does not prevent a provider from potentially receiving an incentive payment if they successfully attest for 2015 later. The exception simply protects the provider from the payment adjustment should they be unsuccessful in their attestation. Those who are unable to attest at all and fall into any of the exception categories may also submit an application.

The Meaningful Use attestation deadline is March 11. Additionally, providers can satisfy the Clinical Quality Measure (CQM) requirement of MU by reporting on Physician Quality Reporting System (PQRS) measures using the Electronic Health Record (EHR) method. The deadline for this is also March 11.

--Erin Solis, Regulatory Compliance Strategist for the American Academy of Family Physicians

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