Gary Swartz, JD, MPA Associate Executive Director AAHCM
1. Provide definition and overview of the need for plan of care 2. Current services, new codes and proposed legislation to produce SGR fix modernize Medicare payment that references plan of care 3. Describe evolving practice standards (e.g., PCMH) that include plan of care 4. Academy resources and advocacy to support your practice and field
Clinical Regulatory/Coverage and Payment POC not currently described with specificity in Part B However, codes under development and evolving practice requirements describe a plan of care (and related practice standards) Majority of home care medicine practice touches upon plan of care Organizational Service/practice development Relationship development
Housecall codes Care Plan Oversight Transitional Care Management Services Chronic Care Management Services Regulatory development Legislative development
Evaluation and management services Current services New codes and evolving models Shared savings programs Private health plans Transitional care management Health assessments Chronic care management services
E & M Services Care Plan Oversight Preventive Services Annual Wellness Visit Transitional Care Management
2014 Medicare Final Rule Advanced Care Planning 2015? SGR Fix Legislation SGR Fix Legislation SGR Fix Legislation PCMH For Private Health Plans Chronic /Care Management Services Beyond the content of E and M Merit Incentive Payments Alternative Payment Models PCMH or Like Standards for Care Management Services
E & M Services New Codes Chronic Care Management in Medicare Final Rule SGR Fix Legislation SGR Fix Legislation SGR Fix Legislation PCMH for Private Health Plans Current 2015 2015 2015 forward 2015 forward 2015 forward Current
Medicare Coverage Manual (Rev. 1, 10-01-03) B3-15515, B3-15066 A. Requirement for Physician Presence Home services codes 99341-99350 are paid when they are billed to report evaluation and management services provided in a private residence. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary s home.
Medicare Coverage Manual (Rev. 1, 10-01-03) B3-15515, B3-15066 B. Homebound Status Under the home health benefit the beneficiary must be confined to the home for services to be covered. For home services provided by a physician using these codes, the beneficiary does not need to be confined to the home. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit.
G. Documentation for the IPPE or AWV The physician and qualified NPP, or for AWV the health professional, shall use the appropriate screening tools typically used in routine physician practice. Physicians, qualified NPPs, and medical professionals are required to use the 1995 and 1997 E/M documentation guidelines to document the medical record with the appropriate clinical information. (http://www.cms.hhs.gov/mlnedwebguide/25_e MDOC.asp). All referrals and a written medical plan must be included in this documentation.
180 - Care Plan Oversight Services (Rev. 999, Issued: 07-14-06; Effective: 01-01-05; Implementation: 10-02-06) The Medicare Benefit Policy Manual, Chapter 15, contains requirements for coverage for medical and other health services including those of physicians and non-physician practitioners. Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare-covered services provided by a participating home health agency or Medicare approved hospice. CPO services require complex or multidisciplinary care modalities involving: Regular physician development and/or revision of care plans; Review of subsequent reports of patient status; Review of related laboratory and other studies; Communication with other health professionals not employed in the same practice who are involved in the patient s care; Integration of new information into the medical treatment plan; and/or Adjustment of medical therapy.
180 - Care Plan Oversight Services (Rev. 999, Issued: 07-14-06; Effective: 01-01-05; Implementation: 10-02-06) The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physician s time per month. Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to: Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment; Time spent by staff getting or filing charts; Travel time; and/or Physician s time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies. Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient s care with the home health agency or hospice during the month for which CPO services were billed. The physician who bills for CPO must be the same physician who signs the plan of care. Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight. These non-physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services. These non-physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare-covered home health or hospice service.
Physical assessment Mental assessment Cognitive assessment Functional assessment Environmental assessment
, the term plan of care is not a defined term under Medicare Part B.. there is general understanding of a plan of care as one (MD/NP/PA), applies the term to patient care within one s own practice or organization, there is no standard across Academy members or across medical practices in general. Additionally, medical records, (paper and electronic), presentation and functionality vary from practice to practice in terms of how and where the plan of care is documented and is linked to other areas in the record. Finally, there is reference to plan of care again without specific definition of the term in a limited number of accreditation organization standards. As a result, the Academy provides the following materials 1) for Academy members who have submitted IAH applications, 2) for CMS (contractor) use in evaluating IAH satisfaction of the plan of care provisions and 3) for Academy member practices seeking guidance in establishing practice policies and procedures. AAHCP Recommendation Definition of Plan of Care The plan of care refers to the process, content, actions, and related documentation that includes the elements and standards listed below. Medical record documentation will reflect the process, content and actions. Accordingly, the plan of care is not a specific form.
Patient Goals and Advance Directives Prognosis Life Expectancy Problem List Cognitive/Functional Assessment Decisional Capacity Symptom Management Medication Management Environment Safety Evaluation Caregiver and Family Assessment Community/Social Ordered Services, Home Health, DME, Hospice, Community Based Services
Problem List Expected Outcome and Prognosis Measureable Treatment Goals Symptom Management Planned Interventions Medication Management Community/Social Services Ordered Services, Home Health, DME, Hospice, Community Based Services How the Services of Agencies and Specialists will be Directed/Coordinated Identification of the individuals responsible for each intervention, requirements for periodic review, and revision of the care plan PRN
CMS has concern regarding (in-home) assessments used for diagnostic coding without subsequent follow-up medical care and involvement of primary care provider
CMS supports the use of enrollee risk assessments for wellness, care coordination, and disease prevention. We also support such assessments as a tool for identifying beneficiaries in need of treatment. If medication management is improved and hospitalizations are avoided, beneficiaries receive better quality of care and MA organizations face reduced costs of care. However, there appears to be little evidence that beneficiaries primary care providers actually use the information collected in these assessments or that the care subsequently provided to beneficiaries is substantially changed or improved as a result of the assessments. Therefore, we continue to be concerned that in-home enrollee risk assessments primarily serve as a vehicle for collecting diagnoses for payment rather than serve as an effective vehicle to improve follow-up care and treatment for beneficiaries.
Further, to the extent that the commenters believe that home assessments improve care, and are not just efforts to increase the diagnoses collected, we request that the commenters submit suggestions for specific and measurable ways that CMS could operationalize to use certain diagnoses from home visits for risk adjustment purposes in 2015. For example, we could establish a requirement that beneficiaries have a medical visit in a primary care setting within 60 days of the home visit in order for the diagnoses from the home visit to be used for risk adjustment. Any proposed approach to use certain diagnoses from home visits for risk adjustment purposes would need to address our concerns about coding efforts that do not have associated plan liability for medical care and would need to allow us to determine whether and how MA organizations are using home visits to improve care.
CMS concern can be used to; describe/leverage your services to provide home based primary care as part of health plan network develop care coordination and shared savings type services for health plans home limited high cost/high utilization enrollees
Codes under development require plan of care Codes under development will require patient centered medical home (PCMH) or similar approved standards to be met for payment
History Current status Recognition Private health plans Emerging within Congress and Medicare program Practices adoption Percent of practices that have in place/under consideration Impediments to adoption Resources Cost Expertise, operations Lack of payment
Access to Care (when and how available during and after hours) Continuity of Care (who and how assured) Definition of responsibilities of practice Definition and Operation of Practice Team EMR--Recording and Use of Patient Information for Population Management Planning and Managing Care using evidence-based guidelines identifying high risk patients, plan of care medication management including med. Reconciliation electronic prescribing EHR Using Certified EHR technology Self-Care Support (providing plan, educational booklets, counseling on health behavior) Referrals to community resources (providing list, tracking referrals, arrange or provide treatment (MH only), classes) Tracking and Coordinating care (lab, imaging, specialist referrals) Coordinating with Facilities and Managing Care Transitions (hospitals, ER, other facilities without naming) Measuring and Improving Performance (reporting clinical measures, getting patient/family satisfaction feedback, having a CQI process and tracking improvement, reporting performance internally and externally
Private health plans and requirements Medicare - Legislative Care management services 2015 5% bonus to practices 2018 forward PCMH or Similar approved by the Secretary Academy advocacy Medicare - Regulatory Chronic care management services 2015 (recognize non face to face services) AMA CPT Codes Proposed rule 2014 Medicare G Code - Final rule 2014 Survey about to start value and payment to be established Standards development PCMH or similar with accreditation/certification Academy advocacy
Requirement Partner Vendor Relationship Access to Care (when and how available during and after hours) Continuity of Care (who and how assured) Definition of responsibilities of practice Definition and Operation of Practice Team EMR--Recording and Use of Patient Information for Population Management Planning and Managing Care using evidence-based guidelines identifying high risk patients, plan of care medication management including med. Reconciliation electronic prescribing EHR Using Certified EHR technology Self-Care Support (providing plan, educational booklets, counseling on health behavior) Referrals to community resources (providing list, tracking referrals, arrange or provide treatment (MH only), classes) Tracking and Coordinating care (lab, imaging, specialist referrals) Coordinating with Facilities and Managing Care Transitions (hospitals, ER, other facilities without naming) Measuring and Improving Performance (reporting clinical measures, getting patient/family satisfaction feedback, having a CQI process and tracking improvement, reporting performance internally and externally
National Committee for Quality Assurance The Joint Commission Accreditation Association for Ambulatory Health Care URAC
Information technology expenses Medical equipment expenses Medical supply expenses Clinical facility expenses Physicians Non-physician providers Registered nurses LPNs, MAs
Organize to support plan of care based approach to services (majority of your services and revenue) New codes/practice standards established around plan of care Academy advocacy on codes and regulation Advocate for payment for services you render (both face to face and non face to face, personally and through practice staff) Focus on high cost multimorbid population include home care medicine/hbpc as requirement to render service and to receive payment Practice standards should provide and support home care medicine and not include requirements that are not relevant to the care of the population nor supported by evidence Prepare this year for the codes, services and payment systems Develop practice relationships that support plan of care based services Academy Resources
Resources Booklets The Field Guide E-communications Academy website Annual Meeting 2014 Presentations Advocacy Code surveys Participation in multi-specialty group with CMS and others Interaction with Congress and CMS Standards development steering committee
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