Physician payment: present and future The devil of the details
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1 Physician payment: present and future The devil of the details John D. Goodson MD, FACP Massachusetts General Hospital Harvard Medical School
2 The future of PC MD payments IPPE, 2005 AWV codes, 2011 TCM codes, 2013 CCM codes, 2015 E/M codes Rework,??
3 My goals 1. Know the origins of RBRVS, our monetary system, and how physician services are valued in The Game of Codes 2. Review the rules for E/M codes 3. Learn to use the new IPPE, AWV and TCM service codes and you will benefit. This is a win/win/win 4. The CCM code could fill the final compensation gap
4 Welcome to the land of RVUs The world we live in
5 Let s talk about coding: Kreb s vs. RBRVS
6 Key terms What: CPT (Current Procedural Terminology): What we do, descriptions of services. Proprietary to the AMA, usage fee. HCPCS (Healthcare Common Procedure Coding System). CMS rendition of CPT Why: ICD (International Classification of Diseases): The code assigned to each disease or condition RVU (Relative Value Unit): The coin of the realm
7 All models of care delivery use RBRVS building blocks to calculate the work done Salary models use the PFS to establish productivity goals/bonus thresholds. PCMH compensation models derived from the services delivered by each clinician based on the PFS ACO revenue distribution derived from the relative values assigned to the work done by each clinician based on the PFS
8 The origins of E/M undervaluation began at the beginning The journey to the land of RBRVS:
9 The road to RBRVS: In the beginning 1983: HCFA chooses CPT as exclusive source for Healthcare Common Procedure Coding system (HCPCS) 1980s: Medicare payment crisis from usual and customary payments, Congress reacts 1985: HCFA begins RBRVS study. CPT 4 has 7000 codes (6900 are for procedures) : Hsiao study and his assumptions: Payment for work and costs Intensity = tech skill, mental/physical effort, psychological stress (not time!) Time intervals: Pre, intra and post-service
10 1988: The Harvard Report, Hsiao and Braun
11 The Evaluation and Management dilemma: The compression effect Hsiao was forced to compress a wide range of E/M activities into the small range of E/M codes. Pre 1992 E/M 1992 E/M #Vignettes New, extended New, comprehensive Estab, Intermediate Estab, Extended Kumetz and Goodson Chest 2013: 144:1-6
12 The road to RBRVS: The research basis of policy : Hsiao study: Technical consulting groups (N=17) Professional societies, 85% proceduralists. Established relativity of intra-service work for 400 vignettes National survey on 3200 MDs, asked to compare vignette intra-service intensity to other services TCGs matched vignettes to existing CPT codes CPT then linked across services by a selected panel of 24 (19 were proceduralists) Relatively in families extrapolated from contemporaneous Medicare charge data
13 E/M payment care continues to be influenced specialists CPT Editorial Panel or Professional Society MD Surveys by Societies CMS Medicare Payment Schedule AMA Relative value Update Committee (RUC) 90% recommendations accepted without change by CMS,
14 RBRVS in the monetary system of health care payment Resource-based relative value scale (RBRVS) Weighted system Assigns worth = RVUs to each CPT code 3 components: Total RVUs = W + P + M Work Clinical work (52%) Practice Expense overhead (44%) Malpractice liability insurance (4%) RVUs = coin of the realm = units of payment = our Euros = $35.8 in 2014
15 What the RBRVS E/M model does NOT cover Non face-to-face care Telephonic Electronic Off hours care Transitions of care Care management Disease prevention: screening/vaccinations Counseling/coaching Health promotion Prescription management Chronic care management
16 Is there hope for primary care CMS recognizes the dilemma faced by primary care physicians CPT controlled by AMA RUC controlled by AMA and dominated by proceduralists Only one E/M code set, new and established used by all MDs PC MDs need access to more RVUs but how??
17 The future of PC MD payments IPPE, 2005 AWV codes, 2011 TCM codes, 2013 CCM codes, 2015 E/M codes Rework,??
18 Medicare choices for problem oriented care SERVICE Problem focused clinical care : New Patients Established Patients IPPE (Welcome to Medicare) G0402 AWV (Annual Wellness Visits) G0438 (first) G0439 (subsequent) PATIENT COSTS Subject to co-insurance and/or deductible 100% During 1 st year of Part B Enrollment 100% after 1 st year of Part B Enrollment, annual benefit
19 The future of PC MD payments IPPE, 2005 AWV codes, 2011
20 TWO Medicare wellness and prevention service codes SERVICE Problem focused clinical care : New Patients Established Patients IPPE (Welcome to Medicare) G0402 AWV (Annual Wellness Visits) G0438 (first) G0439 (subsequent) PATIENT COSTS Subject to co-insurance and/or deductible 100% During 1 st year of Part B enrollment 100% after 1 st year of Part B enrollment Annual benefit (+ 366 days)
21 IPPE Welcome to Medicare documentation requirements 1. Establish individual s medical/family history. 2. Review of the individual s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders 3. Measure individual s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary s medical/family history. 4. Review functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire 5. PE 6. Optional end of life discussion
22 IPPE Welcome to Medicare documentation requirements (cont.) 7. Education and counseling based on PMH, RFs, functional/safety status, PE, end of life discussion 8. Provide a written plan for obtaining appropriate services: AAA screening, CV screening, DM screening, nutrition, PAP/pelvic, EKG, BMD, colon CA screening, prostate CA screening, vaccinations, glaucoma screening and mammogram.
23 IPPE Welcome to Medicare documentation requirements (cont.) 7. Education and counseling based on PMH, RFs, functional/safety status, PE, end of life discussion 8. Provide a written plan for obtaining appropriate services: AAA screening, CV screening, DM screening, nutrition, PAP/pelvic, EKG, BMD, colon CA screening, prostate CA screening, vaccinations, glaucoma screening and mammogram. But only about 5 % of Medicare beneficiaries receive an IPPE!
24 Annual Wellness Visit (AWV) documentation requirements (2011) 1. Update medical and family history 2. List current providers and suppliers actively involved with individual care 3. List medications, prescription and nonprescription 4. Measure height, weight (BMI), BP and other routine measurements 5. Provide a plan of care for screening, vaccination, health promotion
25 Annual Wellness Visit (AWV) documentation requirements (2013) 6. Provide a Health Risk Assessment (HRA). 7. Address concerns highlighted by HRA questionnaire 8. Develop a data base for each patient -- Retained in your EHR -- Updated at subsequent AWVs
26 What is a Health Risk Assessment (HRA)? I. Activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) --Physical risks: Frailty/fall risk, home safety --Behavioral risks: EtOH, smoking, seat belt use, risk taking --Self-care risks: Nutrition, dressing, hygiene, medication management -- Independence risks: Shopping, food preparation, housekeeping, laundry, telephone communication, finances. II. Mental health --Depression --Other: including stress, anger, isolation
27 Key point: AWVs can stand alone or have an added E/M visit The E/M must be submitted with a -25 modifier. The decision to combine service codes can only be made by the clinician. This cannot be done by anyone else!
28 Example of combining service codes For example: 66 year old established patient is seen for Initial Annual Wellness Visit The visit also addresses the management of her HTN, DM and hypercholesterolemia. She is on 5 medications. Labs are ordered. Coding= G0438 (Initial AWV) = = 3.93 work RVUs = 8.02 total RVUs = $287.16
29 The future of PC MD payments TCM codes, 2013
30 : Transitional Care Management (TCM) codes: --Medicare s incentive to manage patients as they leave facilities an return to home --This is a bundled payment for PC services for 29 days of care (i.e. the bill can be submitted starting day 30)
31 99495 TCM services (moderate): Communication by direct contact (face to face), telephone or electronically with the patient and/or caretaker within 2 business days of discharge A face-to-face encounter with 14 days MDM of at least moderate complexity Work RVUs = 2.11 Total 4.82 (non facility) and 3.96 (facility) = $ (non facility)
32 99496 TCM services (high): Communication by direct contact (face to face), telephone or electronically with the patient and/or caretaker within 2 business days of discharge A face-to-face encounter with 7 days MDM of high complexity Work RVUs = 3.05 Total 6.79 (non facility) and 5.81 (facility) = $ (non facility)
33 Services (face-to-face or non face-toface) provided by clinical staff Communication With the home health agencies and other community services utilized by the patient. With patient and/or family/caretaker, education to support self-management, independent living, and activities of daily living. Assessment and support for treatment regimen adherence and medication management. Identification of available community and health resources. Facilitate access to care and services needed by the patient and/or family.
34 Services (face-to-face or non face-toface) provided by the physician or other qualified health care provider Obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care documents). Reviewing need for or follow-up on pending diagnostic tests and treatments Interact with other qualified health care professionals who will assume or reassume care of the patient s system-specific problems. Educate patient, family, guardian, and/or caregiver. Establishment or reestablishment of referrals and arranging for needed community resources. Assistance in scheduling any required follow-up with community providers and services.
35 Billing issues: TCM codes include all clinical services on the day of face-to-face visit as well as the totality of related TCM care within the 29 day billing period. The day count starts on the day of discharge. For a patient discharged on Wednesday, the professional staff (RN, NP, PA, or MD) has until Friday to contact the patient. Business days exclude holidays. Contact counting based on business days, F2F based on calendar days.
36 Other key points: An attempt to make contact (phone or eamail) with the 2 days of discharge is defined as two or more unsuccessful attempts at communication within a timely fashion. If the office does not reach the patient, documentation of attempts should be sufficient. TCM codes can be billed by any clinician. No prior relationship is required. TCM services can be submitted by the same providers who submit charges for hospital, rehabilitation or observation discharge.
37 Workflow: Know discharge date Patient leaves facility 2 days Patient needs assessed by smart triage No TCM 7 day 14 day F2F F2F 30 day review 30 day review
38 Workflow: Smart triage Patient leaves facility 2 days Patient needs assessed by smart triage No TCM 7 day 14 day F2F F2F 30 day review 30 day review
39 Workflow: 29 days work and wrap up Patient leaves facility 2 days Patient needs assessed by smart triage No TCM 7 day 14 day F2F F2F 30 day review 30 day review
40 Team work and pass offs Communication and responsibility are essential components Patient identification at moment of discharge (day of admission?): MD, CM, RN, Sec, Enterprise Patient contact and triage: MD, RN, CM Scheduling of office visit: RN, CM, Sec Office visit: MD
41 Documentation Options Templated note Paper documentation (can include documentation elements and tracking of call/visit) Who contributes which elements? Separate notes accumulating over time? Shared notes? One note added to over time?
42 The future of PC MD payments CCM codes, 2015
43 Chronic care management: A new code for non face-to-face (NF2F) care Available January 1, 2015 CMS recognizes that there are many services provided by PC MDs that are not covered in the E/M service code paradigm (i.e. that NF2F care is part of the post visit time included in a service code assumptions, 10 minutes for a 99214)
44 Which patients will be eligible for CCM code billing? Any Medicare patient, expected to live 12 months or until death Patients with two or more chronic conditions One CCM provider per Medicare beneficiary No prior IPPE (Welcome to Medicare) or AWV (Annual Wellness Visit) is required. Non Medicare carriers have no obligation to pay for CMS or CPT defined services.
45 Other service code exclusions Home health care (VNA) supervision (HCPCS G0181) Hospice (HCPCS G0182) TCM services ( ) All service codes applicable to patients in a facility (e.g. nursing home) settings.
46 What will be the patient payment implications? Code will be billable for 30 day periods in which the medical needs of the patient require establishing, implementing, revising, or monitoring the care plan. The service will be subject to at 20% copayment (or covered as part of a Medicare Part B supplement). Monthly CCM billing can continue indefinitely without face-to-face contact or renewal of the agreement
47 What will be required? Documentation in the patient s electronic medical record that all chronic care management services have been explained and accepted. Written consent for communication with other treating providers. EHR availability 24/7. Communication via telephone or secure asynchronous NF2F messaging. EHR documentation of CCM services provided and time spent.
48 What will the practice/clinician be expected to provide? Continuity of care with a clinician or practice Care management that provide the following: A systematic assessment of medical, functional and psychosocial needs A system-based approach for timely delivery of preventive services Medication reconciliation, both prescription and non prescription, and a review of interactions and adherence An updatable patient-centered plan of care document
49 What is a plan of care document? A problem list, expected outcome and prognosis, measurable treatment goals, and symptom management Planned interventions Medication management Community/social services ordered and how services of agencies and specialists connected to the practice will be directed/coordinated, Identification of the individuals responsible for each intervention Periodic review and revision
50 What is still unresolved? Will higher EHR standards be expected such as real time order entry 24/7? Who will be expected to deliver CCM services, MDs, trained case managers? Original proposal includes a job description. Will detailed written protocols be required and what does this mean? Will PCMH or the equivalent certification be required and which certifications will be accepted?
51 What will be the RVU value of the CCM code? How with the RVUs assigned to the CCM service code be distributed? Work RVUs vs. Practice Expense RVUs Practices will have to consider how to amortize the costs so that those patients who consume higher resources are balanced by those who consume fewer resources, knowing that all patients will receive a minimum 20 minutes of care every 30 days.
52 What is the AMA s CPT doing? The AMA s CPT has developed three CCM service codes for patients with high levels of instability, the option of a F2F visit and the option of expanding the time by 30 minute increments per month. CPT has now collapsed this to one service code but likely only for the most complex
53 What are the implications for practice? How broadly will CMS pitch this code? To 70% of Medicare beneficiaries or 10%? Will RVUs be sufficient to scale for small practices if broadly applicable or for large enterprises if only for the very sick? Will specialists use these codes more than PC MDs? Will Medicare beneficiaries accept CCM billing?
54 Medicare payment reforms For a hypothetical physician with 500 Medicare patients: Revenue from (3 visits per patient per year) = 1500 x 3.13 x $35.82 = $168,175 WITH 10% bonus of $1,681= $184,992 Added revenue for subsequent AWVs = 500 x 3.26 x $35.82 = $58,387 Added revenue for TCMs (60 moderate and 20 high MDM discharges, 60 x 4.82 x $5.82 = $10,359 and 20 x 6.79 x $35.82 = $4,864) = $15,223 Total NEW PC revenue = $75,291 (total $243,466))
55 Summary points 1. E/M is at a disadvantage in the RBRVS 2. IPPE, AWV and TCM service codes offer opportunities to improve compensation 3. CMS documentation stipulations are meant to ensure value for beneficiaries 4. Workflow collaboration, communication and responsibility are essential components 5. EHRs must support the workflow and the documentation
56 Thank you
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