Practice Management Track: Secure Your Practice: Learn the Elements to Deliver, Document, and Get Paid for Key Family Medicine Services Barbie Hays Kent Moore Cynthia Hughes, CPC, CFPC ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. The following Individuals in a position to control content relevant to this activity has disclosed the following relevant financial relationships: Cynthia Hughes, CPC, CFPC, and Barbie Hays, AAFP Staff, Cindy Hughes Consulting (Medical coding and compliance) The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Learning Objectives Documenting and Getting Paid for Chronic Care Management and Transitional Care Management: 1. Identify when Medicare patients are eligible for the transitional care management (TCM) and chronic care management (CCM) services. 2. Summarize the scope of TCM and CCM services expected by Medicare. 3. Understand what is needed to get Medicare patient agreement before providing and billing CCM services. 4. Understand how to document, code, and bill Medicare for TCM and CCM services. Learning Objectives You Did the Work, But How Do You Know You Got Paid: 5. Learn how lost revenue impacts the entire practice (including salaried physicians). 6. Learn the early indicators of potential loss of revenue. 7. Learn processes and policies that support payment collection and may protect against lost revenue. Learning Objectives Evaluation and Management Coding - Doing it Right: 8. Identify the key elements of Evaluation and Management documentation. 9. Understand basic requirements with real world scenarios provided. 10.Apply time-based coding when applicable. 11.Increase awareness of Office of Inspector General OIG Red Flags and Audit concerns. 1
Evaluation and Management Coding: Doing it Right Barbie Hayes E/M Documentation What is the reason for evaluation and management documentation? #1 - To get paid #2 To tell the patient s story 8 E/M Documentation CMS national reimbursements 99212 $44.20 (.48 work RVU) 99213 $73.30 (.97 work RVU) 99214 $108.88 (1.50 work RVU) 99215 $123.27 (2.11 work RVU) The old woman that swallowed a fly Three components to any E/M note History Examination Medical Decision Making 9 10 She swallowed a spider An ugly picture History Chief Complaint (C/C) History of Present Illness (HPI) Review of Systems (ROS) Past, Family, Social History (PFSH) 11 12 2
She swallowed a bird She swallowed a cat Medical Decision Making The hardest part to understand Composed of three pieces itself Number is diagnosis/type Data Risk All three add up to MDM 13 14 She swallowed a dog The lady is ready to die 15 16 Documentation examples Okay, back to the horse Example One 99213 - $73.30 99214 - $108.88 Difference = $35.58 per patient Example Two 99212 - $44.20 99214 - $108.88 Difference = $64.68 per patient Time based coding Greater than 50% of time spent face-to-face Of this minute visit Specific to patient s care/treatment options Don t bill more in time than you have in a working day! 18 3
Practice recommendation Q & A Document what you did Do what you document Get paid for doing it right Contact information Barbie Hays, CPC, CPMA, CPC-I, CEMC bhays@aafp.org 913-906-6000 x4176 You Did the Work, But How Do You Know You Got Paid Cindy Hughes, CPC, CFPC 21 Learning Objectives 1. Learn how lost revenue impacts the entire practice (including salaried physicians) 2. Learn the early indicators of potential loss of revenue 3. Learn processes and policies that support payment collection and may protect against lost revenue Key Discussion Topics How physicians are paid The impact of lost revenue Identifying gaps that lead to loss Policies and procedures that support profitability 4
Brief Note on Taboo Topics Government regulations prohibit (eg, antitrust) Specific fees Contractual rates Not taboo Learning how to manage the revenue cycle to capture payment at contracted rates Fictional and published rates of payment Physician Payment Fee for Service Relative Value Units (RVUs) - physician work, practice expense, liability; each X geographic cost index Conversion factor (CF) vary by payer, Medicare national average $35.93 99213 = 2.04 RVU s x 35.93 = $73.30 (non-facility) Physician Payment Productivity Compensation Per Relative Value Unit Base = Work RVUs national 75th percentile X the 50th percentile CF Bonus - Work RVUs national 75th percentile X High Productivity CF Physician Payment Polling Question How is physician payment structured in your practice? A. What is left after overhead expenses are paid B. Base pay plus production bonus C. Production with quality (incentive/withhold) D. Other (percent of collections, salary) Scenario Dr. Joe joined ABC Medical Practice 4 years ago Base pay plus production bonus based on collected revenue Bonus amounts steadily dropping ABC has cancelled plans for EHR upgrade The Impact of Lost Revenue Discussion What are other impacts of lost revenue? Budget Staff Initiatives Practice value 5
Identifying Gaps that Lead to Loss Discussion Learn the early indicators of potential loss of revenue What questions might Dr. Joe ask to determine an underlying cause for his decreased income? Identifying Gaps that Lead to Loss Key Financial Metrics Manager Bob new to practice aware of Dr. Joe s concerns cash flow is down for the practice as a whole What financial reports and calculations should be part of Bob s analysis of this situation? Identifying Gaps that Lead to Loss Gross Collections Collections charges = gross collections percentile Fluctuation in charges and collections Patterns over time slow months Target - Gross collections comparable to average contracted allowables (eg, 35% of fee) Identifying Gaps that Lead to Loss Net Collections (Collections less credit balances) (charges adjustments) X 100 = net collections Target - 95% Identifying Gaps that Lead to Loss Days in A/R Total outstanding A/R average daily charge amount = Days in AR Monthly trending tool Compare by staff member, payer (include patient pay) Target: 30-35, Over 120 days 12-20% Identifying Gaps that Lead to Loss Denial Rate Denied charges / Claims submitted Quarterly Target: 5% (by number of services or charges) 6
Identifying Gaps that Lead to Loss Looking Closer ABC Medical Practice 25% gross collections (35% average contract rate) 87% net collections A/R outstanding 45 days, 25% over 120 days 10% denial rate What do Manager Bob s findings indicate? Identifying Gaps that Lead to Loss Incentives and Penalties 2.5% penalty on Medicare payments AAFP Practice Advancement Division PQRS, meaningful use, value-based modifier 2015-2018 Merit-Based Incentive Payment System (MIPS) 2019 4-9% payment impact, increasing annually through 2022 Policies and Procedures Learn procedures and policies that support payment collection and may protect against lost revenue Policies and Procedures Discussion What policies and procedures could Manager Bob institute to close gaps where revenue is lost? Pre-visit insurance verification, past due balances Visit out-of-pocket expenses, non-covered services Post-service documentation, charge capture Billing/claims unpaid, rejected, and denied claims Collections billing statements, payment plans Oversight metrics, policies and procedure development Policies and Procedures Discussion How are revenue management and billing policies and procedures best implemented in a practice? Barriers? Solutions? Resources http://www.aafp.org/practicemanagement/administration/ownership.html 5 key metrics quickinars and web pages for each metric FPM Toolbox - Financial Vital Signs Worksheet, Charge Capture Tool, Sample Financial Agreement, Sample Patient Financial Hardship Agreement 7
Practice Recommendations Define your role in revenue cycle management. Review your practice s key financial indicators. Contribute to development and support of policies and procedures to prevent lost revenue. Contact Information Cindy Hughes, CPC, CFP chughespbs@yahoo.com Documenting and Getting Paid for Chronic Care Management and Transitional Care Management Barbie Hayes TCM Poll Question #1 Do you provide Transitional Care Management (TCM) in your practice? Yes No TCM Poll Question #2 What is the biggest barrier to providing and getting paid for TCM in your practice? Not staffed to provide this service Contacting the patient within two days of discharge Having the necessary face-to-face visit in the prescribed time frame Understanding which code to use Holding the claim until the 30 th day Other billing issues (e.g. what date of service to use) Other reasons TCM patient eligibility New or established patient Medical and/or psychosocial problems requiring medical decision-making (MDM) of moderate or high complexity Transitioning from inpatient/observation setting to community setting 8
TCM scope: interactive contact Within 2 business days of discharge Contact can be via telephone, email, or face-to-face Can be with the patient or caregiver Documented conversation must include addressing immediate patient needs and status TCM scope: non-face-to-face services Clinical Staff: Contact with patient/caregiver regarding care Communication & coordination of community services Patient/caregiver education Treatment adherence and medication management TCM scope: non-face-to-face services Physician: Obtain/review discharge summary Review diagnostic tests/treatments Communicate with other providers of care Educate patient/caregiver TCM scope: face-to-face services Required within 7 or 14 calendar days of discharge, depending on the code Should demonstrate at least moderate MDM based on the usual E/M guidelines This visit is bundled into the code and is not separately reportable. TCM coding & billing: pulling the process together 99495 - $166.37 Contact within 2 business days of discharge Moderate risk Medical Decision Making (MDM) Face-to-face visit within 14 days of discharge 99496 - $233.57 Contact within 2 business days of discharge High risk MDM Face-to-face visit within 7 days of discharge Medicare quirks 30 days of service to be supplied Place of service is where the face-to-face occurred Date of service is the 30 th day Additional E/M s and services are still reportable See the TCM worksheet in the booklet 9
Applying what you learned Based on what you learned today, how likely are you to provide TCM in your practice? Not at all likely Somewhat likely Highly likely Undecided CCM Poll Question #1 Do you provide chronic care management (CCM) in your practice? Yes No CCM Poll Question #2 What is the biggest barrier to providing and getting paid for TCM in your practice? Do not have a certified electronic health record Not staffed to provide this service Do not have a way to track the time per patient Identifying eligible patients Offering 24/7 access to the care team Getting patients to agree to the service Billing at the appropriate time (e.g. waiting to file a claim until the time threshold is met) Other reasons CCM patient eligibility Have 2 or more chronic conditions (12 months or until death) Conditions pose significant risk of death, acute exacerbation/decompensation, functional decline Comprehensive care plan established, implemented, revised, or monitored CCM tech requirements: Getting the patient ready Certified EHR: 2011 or 2014 editions Be able to communicate electronically (non-fax) with other providers of service Care plan electronically available to team 24/7 Provide patient with copy of care plan (written or electronic) Initial face-to-face required IPPE/AWV Comprehensive evaluation and management Enrollment of patient into service at this visit Potential cost Access to care (for chronic conditions) Signed agreement from patient Authorization to communicate electronically with other care providers How to revoke One practitioner/once per month Right to decline Only one agreement needed (does not expire) 10
20 minute threshold But where do I start? Payment structured for non-physician staff time (physician non-face to face time counts too) Any coordination of care activity counts Examples Home care agency Pharmacy Family/patient calls Start small! Medicare panel Pick most prevalent of diagnoses (dm, htn, hyperlipidemia) Determine who, how, when and RECORD THE TIME SPENT Involve your staff! Applying what you learned Based on what you learned today, how likely are you to provide CCM services to Medicare patients in your practice? Not at all likely Somewhat likely Highly likely Undecided Resources Practice recommendations Start small Involve your staff Take nothing for granted-document all actions 11
Related Sessions Q & A Increase your practice revenue by implementing CCM in your practice Wednesday * 12:45 1:30 pm; Room: Mile High Ballroom 3A Thursday * 9:15-10:15 am; Room: Mile High Ballroom 3A Friday * 10:30-11:30 am; Room: Mile High Ballroom 3A More Questions? Barbie Hays, AAFP Coding and Compliance Strategist bhays@aafp.org Kent Moore, AAFP Sr. Strategist, Physician Payment kmoore@aafp.org 12