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Looking Ahead: Meaningful Use Stage 3 Requirements

July 14, 2015 /1 Comment/in /by

By Jose Lopez, Senior Consultant, The Verden Group

In my recent blog on the proposed changes to Meaningful Use 2 requirements CMS recognized the barriers providers were facing in meeting the Meaningful Use Stage 2 requirements, and proposed a rule to simplify the Measures and Objectives for 2015 and beyond. CMS clearly heard the complaints from providers that meeting the measures were creating workflow issues. The Verden Group applauds these changes and hope they are approved in their entirety.

Let’s look forward now to what lies beyond meeting the revised Stage 2 requirements in 2015 and 2016, to Stage 3. Following a proposed “optional” year in 2017, all providers will report on the same streamlined definition of Meaningful Use at the Stage 3 level in 2018, regardless of prior participation.

CMS has come out with 8 tentative advanced use objectives for Stage 3 designed to align with national healthcare quality improvement efforts, and to promote interoperability and health information exchange which will focus on the triple aim of reducing costs, improving access and improving quality:

  1. Protect electronic health information
  2. e-Prescribing
  3. Clinical decision support
  4. Computerized provider order entry
  5. Patient electronic access to their data
  6. Coordination of care through patient engagement
  7. Health information exchange
  8. Public health reporting

The specific measures for each objective have yet to be defined but if you think the objectives look like Stage 2, then you would be correct. And as with Stage 2, the most challenging objectives appear to be those where the provider does not have direct control over their outcomes: patient engagement (patient use of portals and e-messaging), health information exchange (by states or other entities), and public health reporting (by states or other entities).

While CMS came under fire in 2014 following the fallout of providers being unable to meet Stage 2 requirements, it is vital that practices continue to advance their use of electronic health information. As Medicare and private payers continue their evolution from fee-for-service to pay-for-performance, data is being used to report on quality outcomes and to differentiate high performing practices to patients.

In closing, it is crucial that providers and provider associations provide feedback when CMS proposes rules for Stage 3 to ensure the data being required isn’t arbitrary (as was the case with Stage 2), but that it meets the intent of the HITECH Act to begin with: reducing costs, improving access, and improving quality.

In our next blog on Meaningful Use, we’ll discuss proper Meaningful Use Attestation documentation and the ugly truth no one wants to hear: CMS plans to audit one in every 20 meaningful use attesters.

NCQA PCMH REDESIGN

July 9, 2015 in /by

By Julie Wood MSc. PCMH CCEPCS_logo_VG

Co-Founder, Patient Centered Solutions LLC

The NCQA is in the process of redesigning not only the initial Patient Centered Medical Home recognition process, but also the renewal process for already recognized practices. The redesigned initial recognition process will be part of the 2017 update to the PCMH Standards, and the updated renewal process is part of a major, ongoing redesign intended to streamline the application.

The current NCQA PCMH Recognition process is highly labor intensive for all involved. The process can take anywhere from six months to two years to complete (depending upon your practice size and number of locations), adding up to a significant investment of your practices resources.

In addition to the sheer amount of work involved, the NCQA application process isn’t an easy one to navigate. For example, there are three different places online where you have to go at various stages during the application:

  1. You’ll first log in to obtain your Standards and to buy the ISS Survey Tool. For this you will need to have a Username and Password for the NCQA Online Store.
  2. Then you’ll need a separate Username and Password for the Application portal where you will complete and submit your application.
  3. Lastly, in order to add documentation to the ISS Survey Tool for submission to the NCQA for grading you’ll need another separate Username and Password.

To make matters more complicated, you can’t pay online right now either—payments are only accepted by phone, fax or check.

In order to address some of this complication, in the spring of this year NCQA started a forum called Ideas4PCMH on their website. Representatives from small and large practices, professional societies, health plans, hospitals, accountable care organizations, community health centers, health IT companies, PCMH Certified Content Experts (CCEs), and State-based agencies gathered to form 17 focus groups tasked with developing new ideas for the redesign of their program logistics.

The PCMH redesign strategy includes four major components:

  1. Provide more guidance to practices through new channels, including live support, online resources and improved customer service;
  2. Introduce a streamlined annual check-in for recognized practices rather than requiring a full documentation review every three years;
  3. Use information generated in the course of daily clinical care to support the recognition process; and,
  4. Redesign the online survey tool to be more user-friendly and efficient.

In the current (2014 Standards) submission process they have already streamlined a few things. For example, the time-consuming process of entering percentages into a box in the ISS survey tool is no longer required for any of the meaningful use reports or the Record Review Workbook.

Under the 2011 Standards NCQA introduced ‘pre-validation’ for EHR’s and Practice Management Systems. Despite streamlining, the work required to get credit for pre-validated points after you have achieved recognition requires the equivalent of an add-on survey. For those of you going through the process now, check with your EMR vendors and if a product was pre-validated under the 2011 Standards, NCQA has cross-walked some of those points to the 2014 Standards. I will add a note of gratitude to the IT companies that do complete the pre-validation process—it is costly and time-consuming for them to do so—making it that much easier for practices submitting to the NCQA with these systems in place, and for us here at The Verden Group/PCS when guiding our clients through the process. Under the 2011 Standards some Vendors had as many as 17-21 points towards the 85 you need for a Level 3 Recognition—a really great step in the right direction.

However, while they help streamline some processes, there is also more work involved under the 2014 Standards than any standards that have come before. There is a requirement to provide annual patient satisfaction results and clinical performance data to them once you have your 2014 Recognition. This is to make sure that practices truly are continuing on the PCMH path and not just submitting (and then promptly dropping!) all of the good practices put in to place through the transition process.

One really exciting step in the right direction is that the NCQA has engaged a digital agency with unique expertise in user experience to help design their new online submission platform. During the next three to five months, the agency will talk to focus groups, participate in internal discussions, and review submitted comments. At the end of this first phase of development, the agency will present a design concept for the online platform that supports the updated PCMH recognition process. Their goal is to approve the final design concept later this year with the intent to build and test it in 2016.

The NCQA states, “We all have the same goal—improving the care people receive, their experiences with health care, and the need to reduce costs.” With regard to this statement, I believe that while the current NCQA PCMH model has introduced many benefits to practices and patient care, it is also true that the time and resources this process takes within a practice is enormous. Every practice that we have taken through the NCQA Recognition process has seen the benefits to documenting processes and overall streamlining of care. No one can argue that the system isn’t improved when you close all of the loops where patients can get lost in the cracks, but the resources it takes to do so cannot be ignored.

Also, having taken practices through the renewal process, I am keenly aware that even though you only have to provide documentation for 11 of the 26 Elements, you had better make sure that you are ready and able to provide documentation for the other 15 Elements as they can come back and ask for it at anytime. Generally, they will allow 3 days to provide the information but we’ve seen some cases where the practice has only been given 24 hours to produce documentation (we appeal those requests, of course!).

Here at the Verden Group/Patient Centered Solutions we are sincerely hoping for a sensible and simplified result from this major redesign.

We encourage you to participate in this discussion by sharing your opinions and ideas with the NCQA at: [email protected]

*A Tip for Practices Recognized under 2014 Standards: Under your quality improvement project, change your clinical measures to new ones once you have reached your goal – continuing at 100% would not be acceptable to NCQA 3 years in a row. They expect to see continuous improvement, not improvements achieved and then simply maintained at that target level. So set your goals small in order that they are both easily achievable and allow for incremental upward progression over the course of the three-year period.

CMS Proposes Updates to Medicaid Managed Care Organizations

July 7, 2015 in /by

By Jose Lopez, Senior Consultant, The Verden Group

On May 26th, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule aimed at “improving the quality and performance of Medicaid Managed Care Organizations (MCOs).” The proposed rule is vast, with more than 650 pages of proposed reforms that attempt to align MCOs with existing regulations for other private and public payers. More than half of all Medicaid beneficiaries (at least 39 million individuals in 39 states and the District of Columbia) have coverage through MCOs.

Amongst the proposed provisions are:

  1. Application of a Minimum Loss Ratio (MLR) to Medicaid and CHIP. The most sweeping change is the application of a federal 85% minimum MLR to MCOs beginning in 2017. MLRs measure how much a managed care plan spends on the provision of covered services compared to the total revenue it receives in capitation payments from the state. Applying a common national standard for calculating MLR is intended to allow comparability across states, facilitate more accurate rate setting, and reduce the administrative burden on managed care plans that operate in multiple states or have multiple product lines.
  2. Greater transparency in how states determine plan payment rates. States will be required to give CMS enough information for the agency to understand the data and the reasoning for the rate.
  3. Apply minimum standards to screen and enroll providers.
  4. Increase Provider Network Access by decreasing time and distance limitations for beneficiaries, particularly from services for Pediatric CHIP providers, OB/GYNs, behavioral health providers, and dentists.
  5. Expanding health plans’ responsibilities in program integrity efforts through administrative and managerial procedures that prevent, monitor, identify, and respond to suspected provider fraud.
  6. Establish a Quality Rating System for Medicaid Plans, based on quality factors including clinical effectiveness, patient safety, care coordination, prevention, member experience, plan efficiency, affordability, and management.
  7. Strengthen encounter data submissions from managed care plans to states, and from states to CMS.
  8. Allow Long-Term Care Beneficiaries to change plans or cancel enrollment and move to standard Medicaid coverage if their preferred providers are out of the managed care networks.

The Verden Group applauds these much-needed reforms. The proposed rule will provide greater access for Managed Medicaid beneficiaries located in rural areas, especially for at-risk children enrolled in CHIP. With greater transparency and provider choice, patients will be able to select plans that include practices that have differentiated themselves through innovative and high quality programs.

The two trade groups representing insurers, America’s Health Insurance Plans and Medicaid Health Plans of America, are generally supportive of the regulatory modernization and the thrust of CMS’ proposals, except for the national 85% minimum MLR. However, there is little evidence to suggest it will negatively impact their profits as many states already mandate MLR requirements.

The Verden Group is concerned the MLR mandate may create difficulties for not-for-profit safety-net insurers, which usually cover large numbers of Medicaid beneficiaries with serious and chronic health issues. These plans have profit margins that vary year over year, meaning a large profit surplus one year could be needed to offset significant losses in another year. In addition, state Medicaid agencies may not have enough resources to implement the proposed regulations. As with all regulations, it is important that sufficient resources are provided to ensure the proposed rule does not become an unfunded mandate where the fiscal responsibility falls to those it is intended to help.

The Verden Group encourages our clients to share their thoughts on the proposed rule by commenting publicly at:

https://www.federalregister.gov/public-inspection before the deadline of July 27, 2015.

 

CMS Meaningful Use Stage 2 Proposed Rule

May 21, 2015 /1 Comment/in /by

By Jose Lopez, Senior Consultant, The Verden Group

Jose sat in on a webinar regarding the latest on the MU2 Rule. Here’s the scoop –

CMS has announced a Meaningful Use Proposed Rule of particular interest for practice attesting for Stage 2 in 2015. The proposed rule would streamline reporting requirements. To accomplish these goals, the rule proposes:

  • Reducing the overall number of objectives to focus on advanced use of EHRs (moving from 20 objectives to a core of eight objectives);
  • Removing measures that have become redundant, duplicative or have reached wide-spread adoption;
  • Realigning the reporting period beginning in 2015, so hospitals would participate on the calendar year instead of the fiscal year (to allow hospitals and CAHs the same amount of time as eligible providers to fully implement new EHR technology); and
  • Allowing a 90 day reporting period in 2015 to accommodate the implementation of these proposed changes in 2015 (for 2015 only, returning participants will have to demonstrate meaningful use for a full calendar year in 2016).

Most notably:

  • Eligible providers would no longer be required to demonstrate that five percent of their patients had electronically viewed, downloaded or transmitted their personal health information using a certified EHR. Instead, eligible providers would only have to demonstrate that at least one patient had done so (as Jose says in the video above!)
  • Similarly, providers would no longer have to show that five percent of patients had sent a message using a certified EHR’s direct messaging capability. Instead, providers would only be required to demonstrate that those capabilities had been fully enabled during the reporting period.

There is a 60-day public comment period for this proposed rule, with comments due by June 9, 2015. The team here applauds the changes in this proposed rule and is in full support of its approval!

The Verden Group has been working with an exciting new company, TruMed Systems, on their revolutionary new approach to vaccine storage and management.

March 9, 2015 in /by

They started by asking the question; how would you design a better vaccine storage and handling solution?

Running a vaccine ‘business’ is an essential yet very costly component of your primary care practice. A study conducted by The Verden Group in 2009 quantified the costs of vaccine storage and handling for averaged sized primary care practices (3 providers) and estimated the costs of handling, storage, wastage and missed billing at $16,000 annually.

TruMed Systems looked at the process of vaccine storage and handling and set out to find a better solution. Assembling a network of physicians, nurses, practice managers and vaccine industry experts, they set about designing AccuVaxTM a fully automated vaccine storage and handling solution. We happen to think it’s AWESOME.

We thought we’d share this latest white paper from TruMed – click here to read it and see what AccuVax can do, and how it may help transform your vaccine business.

PCPCC Reports Positive Outcomes of PCMH Initiatives

February 25, 2015 in /by

By Jose Lopez, Senior Consultant, The Verden Group

The Patient-Centered Primary Care Collaborative (PCPCC) recently released The Patient-Centered Medical Home’s Impact on Cost and Quality: Review of Evidence 2013-2014. The report highlights evidence from primary care Patient-Centered Medical Home (PCMH) initiatives taking place in both public and private markets across the country. The report looks at selected outcomes from 28 peer-reviewed studies, state government evaluations, and industry reports published between September 2013 and November 2014. The results are encouraging and demonstrate the PCMH’s positive impact on reducing cost and unnecessary health care utilization.

Summary of Overview: Of the 14 peer-reviewed scholarly publications, 60% of studies reported reductions in cost and 92% of studies reported improvements in utilization. Of the 7 state government reports, 100% reported reductions in cost and 86% reported improvements in utilization Of the 7 industry reports, 57% reported reductions in cost and 86% reported improvements in utilization. Summary of Overview: Of the 14 peer-reviewed scholarly publications, 60% of studies reported reductions in cost and 92% of studies reported improvements in utilization. Of the 7 state government reports, 100% reported reductions in cost and 86% reported improvements in utilization Of the 7 industry reports, 57% reported reductions in cost and 86% reported improvements in utilization.[/caption]

The report concludes key areas integral to the future development of enhanced primary care and the PCMH including: integration into medical neighborhoods and accountable care organizations; financial support for primary care; consumer and public engagement; development of team-based health professions; and the role of technology in the PCMH and primary care.

The Verden Group’s Patient Centered Solutions is focused not just on helping clients achieve NCQA Patient Centered Medical Home (PCMH) and Patient Centered Specialty Practice (PCSP) recognition, we also deliver solutions to help you meet your patient education needs, help you reach pay-for-performance targets, and improve the patient experience at your practice.

We work with each client individually to determine where your practice stands today and identify the work to be done to help you meet your goals. We’ll put a project plan in place, keep you on track, and get you to the finish line.

Single site or multiple sites, primary care or multi-specialty, we help you to navigate the process from application through submission. For more information visit: www.theverdengroup.com/our-services/patient-centered-solutions-services/

Cyber Risk Insurance – Should you consider getting it for your practice?

February 6, 2015 in /by

By Sumita Saxena, Senior Consultant, The Verden Group

The cyber-attack on Anthem, which left 80 million customers and employees vulnerable to identity theft, has quickly elevated the question of whether to purchase cyber risk insurance to the forefront of discussion among healthcare providers. The attack will certainly impact the market of cyber security insurance for healthcare providers, payers and others. Small to medium-sized healthcare organizations that have not considered such coverage may do so now while insurers will be re-evaluating underwriting standards and likely premium levels in the wake of the Anthem attack.

Most policies provide broad coverage for what constitutes a privacy breach, whether it results from a hacker, unauthorized access by an internal rogue employee or a laptop that was lost or stolen. Coverage can be divided into two categories: first-party and third-party costs.

Typically first-party costs involve those direct costs related to responding to a privacy breach or security failure. Such costs include forensic investigation of the breach, legal advice to determine notification obligations, notification costs of communicating the breach, offering credit monitoring to customers or patients as a result, and loss of profits and extra expenses during time network is down (business interruption).

Generally third-party costs include legal defense, settlements or damages or judgments related to the breach, liability to banks for re-issuing credit cards, cost of responding to regulatory inquiries and regulatory fines and penalties. Optional coverage can encompass underwriting for cyber-extortion, where hackers access a network and demand a ransom in exchange for not stealing data (many companies would rather pay the ransom and make the problem go away).

Larger organizations are more likely to purchase coverage than smaller ones given their access to risk managers and in-house IT security. Smaller companies, like physician practices and local clinics, may not have access to such resources and may forego coverage as unnecessary or too expensive. Data breaches, however, are continuing to garner significant attention and some insurance experts have commented that more and more small and mid-sized organizations are actively seeking out this coverage. Premiums for a $1 million plan are generally $5,000 to $10,000 annually though the cost can vary based on several factors, including company revenue, cyber-risk management efforts and the coverage chosen.

The cost of insurance coverage and breach response is minimal, however, when compared to the legal and regulatory costs associated with a data breach, which depending on the size of the attack, can run into the millions and substantially impair a company’s profitability if the response is not adequate.

Any large, well-publicized breach such as the one that struck Anthem will affect the market for cyber security insurance, as noted by industry experts, by influencing coverage terms, increasing coverage prices and making underwriting requirements more stringent, especially for healthcare companies as the industry sees more large-scale breaches. In light of these changes, it is prudent to re-assess network security and adequacy of breach notification, and to consider cyber risk insurance as an additional safeguard against the substantial cost associated with data breaches.

New HCPCS Modifiers Define Subsets of the 59 Modifier

January 23, 2015 in /by

By Jose Lopez, Senior Consultant, The Verden Group

As of January 1, 2015 the Centers for Medicare and Medicaid Services (CMS) established four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier. The Modifier -59, which is used to designate a “distinct procedural service”, is the most widely used HCPCS modifier. It is defined for use in a wide variety of circumstances and is often applied incorrectly to bypass National Correct Coding Initiative (NCCI) edits. In addition, this modifier is associated with considerable misuse and high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases. The introduction of subset modifiers is designed to reduce improper use of Modifier -59 and help to improve claims processing for providers. The new modifiers (referred to collectively as -X{EPSU} modifiers) are:

  • XE – Separate Encounter, a service that is distinct because it occurred during a separate encounter.
  • XS – Separate Structure, a service that is distinct because it was performed on a separate organ/structure.
  • XP – Separate Practitioner, a service that is distinct because it was performed by a different practitioner.
  • XU – Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual       components of the main service.

CMS will continue to recognize modifier -59 but may selectively require a more specific -X{EPSU} modifier for billing certain codes that are at high risk for incorrect billing. When a specific –X modifier describes the circumstances for reporting both codes it should be reported in lieu of modifier -59. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X {EPSU} modifiers are more selective versions of modifier -59, so it would be incorrect to include both modifiers on the same line. As a default, at this time CMS will initially accept either a -59 modifier or a more selective – X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. For further instructions and implementation of the HCPCS Modifiers -X{EPSU}, check with your Medicare Administrative Contractors (MACs) or Private Payers.

CMS Resources:

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf

www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf

www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

The American Academy of Pediatrics Update on Private Payer Implementation of HCPCS Modifiers -X{EPSU}:

www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Pages/Payer-Implementation-of-HCPCS-Modifiers.aspx

Changes to Coding for Brief Emotional/Behavioral Assessments and Developmental Screenings

January 23, 2015 in /by

By Jose Lopez, Senior Consultant, The Verden Group

Effective January 1, 2015, the 96110 code was revised to distinguish it from a new brief emotional/behavioral assessment code 96127. The revision of 906110 clarifies it as an assessment that is focused on identification of childhood and adolescent developmental levels (e.g., fine and gross motor skills, cognitive level, receptive/expressive and pragmatic language abilities, neuropsychological areas [attention, memory, executive functions] and social interaction abilities), rather than behavioral or emotional status, utilizing a standardized instrument.

The new 96127 code is used for brief emotional/behavioral assessment with scoring and documentation using a standardized instrument. This assessment serves as a mechanism to identify emotional and behavioral conditions that previously may have been underestimated and/or undetected in any age population, such as depression screening and attention-deficit/hyperactivity disorder rating scales. This new code was added to differentiate those instruments that look solely or mainly at behavioral and/or emotional issues from developmental screening which are reported with 96110.

A summary of the revision to 96110 and new descriptor for 96127 is as follows:

  • 96110 – Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.
  • 96127 – Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.

A listing of brief emotional/behavioral assessment and developmental screening instruments with their appropriate CPT code is listed in the grid below.

Assessments.Grid

CMS Foregoes Direct Supervision Requirement to Encourage Use of Chronic Care Services

December 22, 2014 in /by

By Sumita Saxena, Senior Consultant, The Verden Group

Medicare will start paying physician practices for chronic care management beginning January 1st, and has carved out an exception to the direct supervision requirement for incident-to-billing, which is often considered difficult to comply with. This change is intended to encourage the effective use of the services according to the 2015 Medicare physician fee schedule regulation published on November 13th.  There are conditions surrounding this new move, including the documentation of a care plan for patients with two or more chronic conditions and the use of interoperable electronic health records.

The American Medical Association (AMA) created new CPT codes for chronic care management in 2013, but CMS instead proposed using HCPCS “G” code. CMS has reconsidered its initial position and will pay physicians for CPT 99490 (chronic care management services, at least 20 minutes of staff time directed by a physician or other qualified health professional, per calendar month). The code is billable for patients who have two or more chronic conditions expected to last at least 12 months or until the death of the patient, if the conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, and “a comprehensive care plan is established, implemented, revised or monitored,” per the regulation.

The new code is both a revenue opportunity and a compliance risk for providers and CMS will be paying attention to how this develops. CMS declined to cover CPT 99487, another chronic care management code, because it doesn’t include face-to-face time with the patient.

CHRONIC CARE: RISKS, REWARDS

To avoid imposing yet a new set of standards for billing management of chronic conditions, CMS stated “it decided to emphasize that certain requirements are inherent in the elements of the existing scope of service for CCM services, and clarify that these must be met in order to bill for CCM services.” They include:

  • Giving patients access to clinicians 24/7 if they have urgent chronic care needs.
  • Managing chronic conditions, including assessment of medical, psychosocial and functional needs, medication reconciliation and review of patient management of medication.
  • Ensuring continuity of care by having patients see the same clinician at successive appointments.
  • Satisfying various documentation requirements. For instance, patients must agree in writing to receive chronic care management services and authorize electronic communication of their medical information with other providers to facilitate care coordination.  Providers must give patients a copy of their care plan and document they received it, and inform patients they can quit receiving chronic care management services at any time.

CMS also eased a regulatory requirement that otherwise could be an obstacle to chronic care management. These services will often be provided by nonphysician practitioners incident-to a physician’s services, which means they can be billed to Medicare under the physician’s provider number at 100% of the fee schedule if they meet certain requirements. Typically, incident-to services have to be provided under the direct supervision of the physician. “Direct supervision” means the physician “must be present in the office suite and be immediately available to provide assistance and direction throughout the service (but does not mean that the supervising physician must be present in the room where the service is furnished),” according to CMS.

That is not always practical in the chronic care management context. With CMS requiring 24/7 patient access to the clinician, CMS recognizes that the physician may not always be available to supervise. CMS created an exception to the incident-to rule, and will require general supervision for chronic care management. General supervision means the services are performed under the physician’s overall control, but he or she doesn’t have to be in the office.

REDUCTION IN NONCOMPLIANCE

The supervision exception for incident-to billing should reduce noncompliance with the incident-to billing rule. CMS extended the supervision exception to incident-to billing for the non-face-to-face portion of transitional care management services which are hospital oriented. On January 1, 2014 Medicare began paying for two new CPT codes:

  • 99495: Transitional care management including communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity; and face-to-face visit within 14 days of discharge.
  • 99496: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of high complexity; and a face-to-face visit within 7 days of discharge.

The codes for transitional care management are designed to encourage primary care physicians to arrange a visit with patients almost immediately after discharge from the hospital with the intent of improving quality of care and reducing readmissions.

Although physicians can bill Medicare for chronic care management incident to the physician’s services, there are still constraints imposed by state scope-of-practice laws. State laws will preempt Medicare rules if it requires direct supervision.

Providers should not bill Medicare for chronic care management if the care plan is unchanged or requires only minimal change, for example medication adjustment. And while chronic care management can be reported on the same day as an evaluation and management service, clinical staff time cannot be attributed to both visits.

The coverage of chronic care management is also tied to meaningful use compliance. To get paid for chronic care management services in 2015, physicians and nonphysician practitioners must use “EHR technology certified to either the 2011 or 2014 edition(s) of certification criteria to meet the final core capabilities for CCM and to fulfill the CCM scope of service requirements whenever the requirements reference a health or medical record,” per the regulation.

For more information please visit: www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2014-Fact-sheets-items/2014-10-31-7.html