RURAL HEALTH REIMBURSEMENT OPPORTUNITIES & UB-04 BILLING CHANGES FOR /8/2016. March 9, Steve Parde Managing Director sparde@bkd.

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1 RURAL HEALTH REIMBURSEMENT OPPORTUNITIES & UB-04 BILLING CHANGES FOR 2016 March 9, 2016 Steve Parde Managing Director Marla Dumm, CPC, CCS-P Managing Consultant 1

2 TO RECEIVE CPE CREDIT Participate in entire webinar Answer polls when they are provided If you are viewing this webinar in a group Complete group attendance form with Title & date of live webinar Your company name Your printed name, signature & address All group attendance sheets must be submitted to [email protected] within 24 hours of live webinar Answer polls when they are provided If all eligibility requirements are met, each participant will be ed their CPE certificates within 15 business days of live webinar Overview of Chronic Care Management (CCM) Services Overview of Advanced Care Planning (ACP) Services Overview of Rural Health Clinic (RHC) UB-04 Detailed Billing Requirements Potential Cost Report Impact of 2016 Detailed Billing Requirements 4 // experience momentum 2

3 5 // experience momentum CHRONIC CARE DISEASE OVERVIEW Population health Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the critical components of primary care that contributes to better health & care for individuals, as well as reduced spending According to Center for Disease Control (CDC), about 2/3 of Medicare beneficiaries 117 million people have two+ chronic diseases Focusing on patients with two or more chronic conditions by providing CCM services can help improve their health care quality & reduce cost 6 // experience momentum 3

4 CHRONIC DISEASE DEFINED Chronic disease is a long-lasting condition that can be controlled but not cured Condition is expected to last at least 12 months or until death of patient Examples of chronic conditions (not all inclusive) Alzheimer s disease & related dementia Asthma Cancer Chronic Obstructive Pulmonary Disease Diabetes Heart failure Hypertension 7 // experience momentum CHRONIC CARE MANAGEMENT DEFINED CMS defines CCM as Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline. 8 // experience momentum 4

5 CCM SCOPE OF SERVICE According to CMS, providing chronic care management to beneficiaries with multiple chronic conditions requires a multidisciplinary care approach 9 // experience momentum CCM multidisciplinary care approach should involve, but not be limited to, the following Communication with other health professionals not employed in same rural health clinic who are involved in patient s care Management of care transitions between & among health care providers & settings, including referrals to other clinicians Follow-up after an emergency department visit or discharges from hospitals, skilled nursing facilities or other health care facilities Coordination with home-based & community-based clinical service providers 10 // experience momentum 5

6 CCM SCOPE OF SERVICE REQUIREMENTS CCM service initiation during an annual well visit (AWV), Initial Preventive Physical Exam (IPPE) or comprehensive E/M visit that is billed separately Provide at least 20 minutes of non-face-to-face care management services in a calendar month Non-face-to-face services provided by ancillary staff MUST BE PERFORMED UNDER DIRECT SUPERVISION Beneficiary access to care management services 24/7 Continuity of care with a designated practitioner or care team member Monitor beneficiary s condition care management of chronic conditions 11 // experience momentum CCM SCOPE OF SERVICE REQUIREMENTS Ensure beneficiary receipt of preventive care services Medication reconciliation Oversight of beneficiary self-management of medications Follow-up after ER visits Help coordinate transition of care 6

7 WHO IS ELIGIBLE TO BILL FOR CCM? 13 // experience momentum Physicians Certified Nurse Midwives Clinical Nurse Specialists Are not eligible core providers in RHC setting Nurse Practitioners Physician Assistants CMS excludes Licensed Clinical Social Workers & Clinical Psychologists as eligible practitioners MEDICARE BENEFICIARY CONSENT Provider cannot bill for CCM services unless he/she secures a written consent from beneficiary Beneficiary must acknowledge provider has explained (list not all inclusive) CCM program Manner in which CCM services will be provided Health information will be shared with other practitioners Only one practitioner can provide these services during a calendar month Beneficiary has right to stop CCM services at any time Patient consent form(s) should include how to revoke service 14 // experience momentum 7

8 NON-FACE-TO-FACE SERVICE DOCUMENTATION Documentation must include Date & time Person furnishing services Description of services Performing medication reconciliation, oversight of beneficiary selfmanagement of medications Ensuring receipt of all recommended preventive services Monitor beneficiary s condition (mental, physical & social) 15 // experience momentum COMPREHENSIVE CARE PLAN Create a patient-centered care plan based on physical, mental cognitive, psychosocial, functional & environmental (re)assessment & inventory of resources (a comprehensive plan of care for all health issues) Provide patient with a written or electronic copy of care plan & document its provision in medical record Ensure care plan is available electronically at all times to anyone within practice providing CCM service Share care plan electronically outside practice as appropriate 16 // experience momentum 8

9 CCM CERTIFIED TECHNOLOGY Requires use of certified EHR technology to satisfy many CCM scope of service elements Technology used to furnish CCM services beginning on January 1, 2016, would be required to meet, at a minimum, requirements included in 2014 certification criteria edition(s) Guidance/Legislation/EHRIncentivePrograms 17 // experience momentum CCM TECHNOLOGY REQUIREMENTS Provider must be able to transmit summary record for purposes of care coordination House beneficiary consent of CCM services House beneficiary receipt of care plan Must have ability to provide a copy to beneficiary Document communication to & from home-based & community-based providers Plan must be accessible 24/7 to all care team members & other providers caring for beneficiary 18 // experience momentum 9

10 CCM BILLING & CPT CODE REQUIREMENTS Chronic Care Management (CPT 99490) According to the CMS Chronic Care Management Fact Sheet, CPT is defined as 19 // experience momentum CCM BILLING & CPT CODE REQUIREMENTS Codes/services that cannot be reported during same month as CCM Transitional care management (CPT codes ) TCM & CCM services may be provided in same calendar month if furnished service periods do not overlap Home health & hospice care supervision (HCPCS codes G G0182) End-stage renal disease service (CPT codes ) Overlap with CMS demonstration or other initiatives that pay for similar services 20 // experience momentum 10

11 2016 CMS PAYMENT Payment for CCM services will be based on the Medicare PFS national average non-facility payment rate when CPT code is billed alone or with other payable services Rate will be updated annually No geographic adjustment Coinsurance & deductible apply 2016 payment rate = $40.82 CONCLUSION New rule from CMS allowing reimbursement for CCM services is a huge change that will allow physicians to Improve patient care for Medicare beneficiaries dealing with chronic diseases Now get paid for work they are already doing to care for chronically ill patients Potentially increase revenue for their rural health clinic providers 22 // experience momentum 11

12 23 // experience momentum WHAT IS ADVANCED CARE PLANNING (ACP)? Making advanced plans for patientdesired care when facing a serious illness Discussions between patients & providers about Future care decisions that may need to be made How beneficiary can let others know about care preferences Explanation of advance directives & other legal documents May also involve completion of standard forms 12

13 ADVANCED CARE PLANNING Care decisions may include, but not be limited to Choosing or refusing diagnostic testing, invasive procedures &/or medication Whether to perform or continue life-sustaining treatment Stating who is allowed to make care decisions when patient cannot ADVANCED CARE PLANNING COVERAGE & BILLING Effective January 1, 2016, ACP will be a stand-alone billable visit in RHC setting CPT code Performed by an RHC physician or qualified health professional Physician Nurse Practitioner Physician Assistant LCSW Licensed Clinical Psychologist 13

14 ADVANCED CARE PLANNING COVERAGE & BILLING ACP services may be furnished on same day as another billable medical visit Only one AIR will be paid Coinsurance & deductible will apply ACP services may be furnished on the same day as an Annual Wellness Visit (AWV) Only one AIR will be paid Coinsurance & deductible will be waived ADVANCED CARE PLANNING BILLING EXAMPLE 14

15 ADVANCED CARE PLANNING BILLING EXAMPLE 30 // experience momentum 15

16 2016 RHC DETAILED BILLING REQUIREMENTS Prior to 2016, RHCs were not required to report CPT/HCPCS codes other than for covered preventive services (i.e., G0101) NEW Effective April 1, 2016, all RHCs, to include those exempt from electronic reporting, will be required to report CPT/HCPCS codes on UB-04 for each service furnished during encounter Appropriate revenue code(s) will be reported for each line item Payment will continue to be made under all-inclusive rate (AIR) DETAILED BILLING QUALIFYING VISIT NEW An RHC qualifying visit is defined by CMS as A medically necessary medical visit (E/M) A medically necessary mental health visit A qualified face-to-face preventive health visit Examples IPPE AWV G0101 well woman breast/pelvic examination Transitional care management (TCM) services & Advanced Care Planning (ACP) now allowed as stand-alone visits Face-to-face, with a core provider, during which RHC services are furnished Includes services furnished incident to core provider during visit 16

17 DETAILED BILLING QUALIFYING VISIT NEW CMS has provided a list of qualifying visit codes that will prompt AIR payment See MLN Matters MM9269, pages 8-10 Includes primarily E/M services, mental health services & covered preventive services (i.e., G codes) NEW CPT procedure codes (i.e., joint injection, lesion removal) are NOT listed as qualifying visits. Therefore, a procedure only encounter will not meet criteria as a billable encounter DETAILED BILLING QUALIFYING VISITS (NEW) Medicare Benefit Policy Manual, Chapter 13, 40.4, Rev. 220, Effective February 1, 2016 Surgical procedures furnished in a RHC or FQHC by a RHC or FQHC practitioner are considered RHC or FQHC services. Procedures are included in the payment of an otherwise qualified visit and are not separately billable. If a procedure is associated with a qualified visit, the charges for the procedure go on the claim with the visit. Payment is included in the AIR with the procedure is furnished in a RHC, and payment is included in the PPS methodology when furnished in a FQHC. NARHC has relayed concern & provider comments to CMS, & this issue is under consideration. CMS should provide a response prior to April 1, 2016, implementation date 17

18 DETAILED BILLING SERVICE LINE NEW Line item on UB-04 that has a qualifying visit CPT/HCPCS code will prompt AIR payment Professional component of qualifying medical service or preventive health service Revenue code 052X Qualifying mental health service Revenue code 0900 Telehealth originating site facility fee Revenue code 0780 DETAILED BILLING ADDITIONAL SERVICES & REVENUE CODES Every RHC service furnished during a billable encounter will be listed on a separate line item on UB-04 with CPT/HCPCS code Qualifying visit service lines will be tied to a 052x, 0900 or 0780 revenue code NEW Additional medical services or incident to services will be reported on separate lines with revenue codes & CPT/HCPCS codes All valid UB-04 revenue codes may be reported EXCEPT FOR 002x-024x, 029x, 045x, 054x, 060x, 067x-072x, 080x-088x, 093x or 096x-310x REMINDER: Sole performance of incident to services does not meet criteria for a billable encounter 18

19 DETAILED BILLING ROLLING CHARGES When multiple services are furnished during encounter, 052x or 0900 revenue code line (i.e., service line) will include total charges for all services on claim EXCEPTION Charge for a covered preventive service (i.e., IPPE, AWV, well woman exam) is listed separately with CPT/HCPCS code & 052x revenue code. Charge is not rolled into total, but is deducted from total charge for purposes of calculating beneficiary coinsurance accurately DETAILED BILLING EXAMPLE 19

20 DETAILED BILLING EXAMPLE MEDICAL Single medical service A single line item will be listed on UB-04, with appropriate 052x revenue code & charge. Payment is made under AIR DETAILED BILLING EXAMPLE MEDICAL + PREVENTIVE Preventive annual well woman exam (i.e., G0101) furnished with a medical visit (i.e., established visit) will not prompt an additional AIR payment, except for IPPE 20

21 DETAILED BILLING EXAMPLE PREVENTIVE SERVICE Furnishing a covered preventive service (i.e., annual well women/breast & pelvic examination G0101) as only qualifying visit will prompt appropriate AIR payment. Calculation of coinsurance/deductible is waived if applicable DETAILED BILLING EXAMPLE MENTAL HEALTH SERVICE Furnishing psychotherapy with patient & family (90834) will prompt an AIR payment. The charge from the additional medication management service (90863) will be listed separately and the charge rolled to the qualifying service line. 21

22 DETAILED BILLING EXAMPLE MULTIPLE MEDICAL SERVICES RHCs will report a separate line item for each service performed during medical encounter. Example: an established patient visit (i.e., 99213) with performance of a simple laceration repair (i.e., 12002) service line (revenue code 521) will prompt AIR payment DETAILED BILLING EXAMPLE MEDICAL + INCIDENT TO Services & supplies furnished incident to core provider s encounter are included in AIR & not separately paid. Service line will include total charges for encounter. An example is an established visit with ordered lab draw and Hep B vaccination. 22

23 DETAILED BILLING EXAMPLE MULTIPLE VISITS/SAME DAY Multiple visits by same patient with more than one RHC core provider, or with same core provider, result in a single AIR payment EXCEPTIONS If patient is seen for qualifying medical & qualifying mental health visit on same date If patient suffers an illness or injury subsequent to their initial visit & requires additional diagnosis or treatment on same day If patient has a medical or mental health visit AND an IPPE on same date of service. Coinsurance/deductible are waived for IPPE service DETAILED BILLING EXAMPLE MULTIPLE VISITS/SAME DAY Modifier -59 should be appended to service line CPT/HCPCS code(s) for additional qualifying visit(s) Revenue Code HCPCS Service Date Service Units Total Charges Payment 052X /3/16 1 $XX.XX AIR YES Coinsurance/ Deductible Applied /3/16 1 $XX.XX AIR YES 052X G /3/16 1 $XX.XX AIR NO 23

24 FINAL THOUGHTS Review current CMS transmittals & instruction for new CCM & ACP services Keep current on CMS instruction for detailed billing through list serves and newsletters Provide internal professional staff training Add codes to clinic fee schedule Monitor provider documentation & compliance with service criteria Review guidelines for detailed billing Work with vendors to implement new billing requirements Monitor claims & remittance advices for appropriate reporting & associated payment Perform internal testing of detailed billing UB-04 claims prior to April 1 REFERENCES Centers for Medicare & Medicaid Services (CMS), MLN Matters, MM9269 Revised CMS, MLN Matters, SE1516 CMS, Pub One-Time Notification, Transmittal 1576 CMS, MLN Matters, MM9234, Transmittal R1576OTN CMS, 42 CFR Parts 405, 410, 411, 414, 425 & 495, Medicare Program: Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016, Final Rule CMS, MLN Matters, MM9269 Revised 2/29/16 National Government Services, Medicare University, Billing Guidelines for Federally Qualified Healthcare Centers, May

25 REFERENCES National Association of Rural Health Clinics (NARHC), Chronic Care Management (CCM) in Rural Health Clinics, Rural Health Clinic Technical Assistance Webinar, Captain Corinne Axelrod, MPH, L.Ac., Dipl.Ac., CMS, Centers for Medicare, Hospital and Ambulatory Policy Group, January 19, 2016 NARHC, Advanced Care Planning (ACP) in Rural Health Clinics, Rural Health Clinic Technical Assistance Webinar, Simone Dennis, MSPH, CMS, Center for Medicare, Hospital and Ambulatory Policy Group, January 10, 2016 NARHC, Chronic Care Management for RHCs Begins 50 // experience momentum 25

26 MEDICARE COST REPORT REIMBURSEMENT Maximum RHC payment per visit for calendar 2016 is $81.32 for nonexempt & freestanding RHCs Hospital-based RHCs with less than 50 beds are not subject to RHC payment per visit limitation Critical Access Hospitals Hospital-based RHCs with less than 50 beds Allowable cost per visit is determined by dividing greater of actual total visits or visits as computed using productivity limits Payment per visit or cost reimbursement per visit remains the same regardless of complexity of service MEDICARE COST REPORT REIMBURSEMENT Total Medicare RHC allowable costs RHC health care staff costs Wages for physicians & mid-levels need to be adjusted for amount related to professional services those related to non-rhc services Costs under agreement Other health care costs Hospital overhead costs Excludes nonallowable costs & non-rhc costs 26

27 MEDICARE COST REPORT REIMBURSEMENT RHC services In-office visits In-office surgical services Nursing home visits including skilled swing bed in hospital Home visits Non-RHC services Emergency 4oom time spent Inpatient rounds Hospital administrative duties X-Ray services Laboratory services MEDICARE COST REPORT REIMBURSEMENT Productivity limits Number of visits used to determine cost per visit may be impacted by productivity limits Applicable to mid-level practitioners & employed & regularly contracted physicians 4,200 visits per physician FTE 2,100 visits per mid-level FTE Calculation is combined, not line-item specific 27

28 MEDICARE COST REPORT REIMBURSEMENT FTE calculation Calculated by dividing productive hours by 2,080 Productive hours is defined as total paid hours minus Vacation Sick leave CME Non-RHC services Administrative duties MEDICARE COST REPORT REIMBURSEMENT Example 1 Number of FTE Personnel Total Visits Productivity Standard (1) Minimum Visits (col. 1 x col. 3) Greater of col. 2 or col VISITS AND PRODUCTIVITY Positions 1.00 Physician ,000 4,200 3, Physician Assistant - - 2, Nurse Practitioner ,800 2,100 2, Total FTEs and Visits (sum of lines 4 through 7) ,800 5, Physician Services Under Agreements

29 MEDICARE COST REPORT REIMBURSEMENT Example DETERMINATION OF RATE FOR RHC/FQHC SERVICES 1.00 Total Allowable Cost of RHC/FQHC Services (from Wkst. M-2, line 20) 1,068, Cost of vaccines and their administration (from Wkst. M-4, line 15) 24, Total allowable cost excluding vaccine (line 1 minus line 2) 1,044, Total Visits (from Wkst. M-2, column 5, line 8) 5, Physicians visits under agreement (from Wkst. M-2, column 5, line 9) Total adjusted visits (line 4 plus line 5) 5, Adjusted cost per visit (line 3 divided by line 6) MEDICARE COST REPORT REIMBURSEMENT Example 1 Prior to January 1 On on After January Per visit payment limit (from CMS Pub , chapter 9, 20.6 or your contractor) Rate for Program covered visits (see instructions) CALCULATION OF SETTLEMENT Program covered visits excluding mental health services (from contractor records) - 2, Program cost excluding costs for mental health services (line 9 x line 10) - 365,400 29

30 MEDICARE COST REPORT REIMBURSEMENT Case Study Now Patient goes to RHC for knee pain Physician performs evaluation & management with injection Physician requests follow-up injection in two weeks Initial evaluation & management & injection by physician is billed as a qualifying RHC visit Subsequent injection by physician is billed as a qualifying RHC visit MEDICARE COST REPORT REIMBURSEMENT Case Study Effective April 1, 2016 Patient goes to RHC for knee pain Physician performs an evaluation & management with an injection Physician requests follow-up injection in two weeks Initial evaluation & management & injection by physician is billed as a qualifying RHC visit Subsequent injection by physician cannot be billed as a qualifying RHC visit 30

31 MEDICARE COST REPORT REIMBURSEMENT Example 2 10% reduction in qualifying RHC visits Number of FTE Personnel Total Visits Productivity Standard (1) Minimum Visits (col. 1 x col. 3) Greater of col. 2 or col VISITS AND PRODUCTIVITY Positions 1.00 Physician ,800 4,200 3, Physician Assistant - - 2, Nurse Practitioner ,420 2,100 2, Total FTEs and Visits (sum of lines 4 through 7) ,220 5, Physician Services Under Agreements - - MEDICARE COST REPORT REIMBURSEMENT Example 2 10% reduction in qualifying RHC visits DETERMINATION OF RATE FOR RHC/FQHC SERVICES 1.00 Total Allowable Cost of RHC/FQHC Services (from Wkst. M-2, line 20) 1,068,000 1,068, Cost of vaccines and their administration (from Wkst. M-4, line 15) 24,000 24, Total allowable cost excluding vaccine (line 1 minus line 2) 1,044,000 1,044, Total Visits (from Wkst. M-2, column 5, line 8) 5,220 5, Physicians visits under agreement (from Wkst. M-2, column 5, line 9) Total adjusted visits (line 4 plus line 5) 5,220 5, Adjusted cost per visit (line 3 divided by line 6) Decrease in the adjusted cost per visit (13.10) Medicare visits 1,955 Medicare reimbursement impact (25,620) 31

32 MEDICARE COST REPORT REIMBURSEMENT Strategies Absolutely critical to develop & maintain accurate RHC physician & midlevel RHC time studies to determine Productive time in RHC Consider electing to file consolidated RHC worksheets in advance of cost reporting period MEDICARE COST REPORT REIMBURSEMENT Strategies RHC physician & mid-level time studies Purpose is to determine allowable RHC productive time & costs Review contract what does he/she get paid for? Determine RHC physicians & mid-level roles, responsibilities & duties Track physician & mid-level RHC productive time, professional time & other 32

33 MEDICARE COST REPORT REIMBURSEMENT During RHC hours of operation RHC face time with patient Time available in RHC not seeing patients RHC qualifying swing bed visits RHC qualifying nursing home visits RHC dictation & charts Medical staff meetings Board meetings MEDICARE COST REPORT REIMBURSEMENT During RHC hours of operation Emergency room time Emergency room dictation & chart review Inpatient round time Inpatient round dictation & chart review Surgery assistance EKGs Providing community education 33

34 MEDICARE COST REPORT REIMBURSEMENT During RHC hours of operation Primary call pay nonallowable Back-up call pay nonallowable Outside RHC hours of operation Medical staff meetings Board meetings Emergency room time Emergency room dictation & chart review MEDICARE COST REPORT REIMBURSEMENT Outside RHC hours of operation Inpatient round time Inpatient round dictation & chart review Primary call pay Back-up call pay Other Continuing medical education Vacation time Sick leave 34

35 MEDICARE COST REPORT REIMBURSEMENT Chronic Care Management Costs CMS will be adding a line to report costs associated with CCM costs Reimbursed on physician fee schedule Excluded from RHC cost per visit Separately identify & track CCM costs QUESTIONS? 35

36 CONTINUING PROFESSIONAL EDUCATION (CPE) CREDITS BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: The information in BKD webinars is presented by BKD professionals, but applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any matters covered in these webinars. The following information was used as a visual aid during a presentation/training session led by a BKD, LLP advisor. This content was not designed to be utilized without the verbal portion of the presentation. Accordingly, information included on these slides, in some cases, are only partial lists of requirements, recommendations, etc. & should not be considered comprehensive. These materials are being issued with the understanding they must not be considered legal advice. 72 // experience momentum 36

37 CPE CREDIT CPE credit may be awarded upon verification of participant attendance For questions, concerns or comments regarding CPE credit, please the BKD Learning & Development Department at THANK YOU! FOR MORE INFORMATION Steve Parde Marla Dumm

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