Tag Archives: CMS

CMS’s Journey To Value-Based Care

Most people think of CMS (Centers for Medicare & Medicaid Services) as an insurance company that covers individual services provided by physicians, FQHCs, hospitals, and other health care providers. Some people even think of it as a policy-writing agency for Medicare. It is true that CMS reimburses providers for services to millions of individual beneficiaries. However, since the Affordable Care Act came into action in 2010, CMS has been developing focused payment strategies that shift from fee for services to value-based care and a focus on population health.

Today, CMS’s second-highest strategic priority is prevention and population health. To this day, the agency is engaged in numerous activities to promote effective prevention of chronic diseases and not just its treatment.

In 2011, the federal government reported that fewer than half of all adults aged 65+ were regular in checking the core set of recommended preventive services. The Affordable Care Act took a big step towards improving the access to preventive care by eliminating out-of-pocket costs for these preventive services in most insurance markets. This resulted in guaranteed access to preventive services like diabetes screening and cervical cancer screening to almost 137 Million Americans without cost-sharing.

Despite improved access to care, the use of preventive services among seniors with traditional Medicare coverage has not changed significantly. There are several hindrances that inhibit the greater uptake of preventive services. A 2014 survey reveals that only 43% of adults were aware of the new clinical preventive benefits provided by the Affordable Care Act. Of those who were aware of the services, 18% cited cost as a barrier, even though the Affordable Care Act eliminated co-payments for preventive services.

Another obstacle is that many Americans believe that preventive services are not important. Thus, even though many cost barriers have been removed, many Americans still might not perceive preventive services as valuable to their health and well-being. This mindset needs to change.

Shifting the paradigm of preventive care requires CMS and other payers to provide incentives beyond individual services to broader value-based and lifestyle interventions that can change population outcomes. To address this issue, CMMI has developed 2 payment models:

(1) The Million Hearts Cardiovascular Risk Reduction Model:

This model associates payment with population-based risk reduction. It is expected to reach over 3.3 million Medicare fee-for-service beneficiaries and involve nearly 20,000 health care practitioners by December 2021.

(2) The Medicare Diabetes Prevention Program:

This program ties payments to the achievement of weight loss through evidence-based lifestyle intervention.

CMS collaborated with sister agencies such as the Centers for Disease Control and Prevention (CDC) to develop these population health models, and they are good examples of how CMMI is using the Medicare payment structure to improve prevention and population health.

These path-breaking innovations offer an opportunity for CMS to test payment models that emphasize payment for population health outcomes rather than just individual outcomes, with the goal of better care and a healthier population.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298510/#bibr11-0033354916681508

https://innovation.cms.gov/innovation-models/million-hearts-cvdrrm#:~:text=The%20Million%20Hearts%C2%AE%3A%20CVD%20Risk%20Reduction%20Model%20is%20expected,and%20end%20by%20December%202021

CMS expands Telehealth Services to Deliver Care Safely during COVID-19 and Beyond

During the COVID-19 pandemic, CMS has taken the necessary steps to make it easier to provide quality care through telehealth services. This unprecedented action by CMS has encouraged healthcare providers to adopt and use telehealth as a way to safely provide care to their patients in situations like medication consultation, eye exams, nutrition counseling, behavioral health counseling, and routine health check-ups like annual wellness visits. Past data have shown telehealth to be an effective medium for patients to access healthcare providers especially for managing chronic conditions like diabetes, asthma or to obtain mental health counseling.

Advantages of CMS changes to Telehealth:

Telehealth services made permanent post-COVID-19:

CMS has announced that 60 of the 144 telehealth services that were newly offered during the pandemic will become permanent. This includes services for cognitive assessment, psychological and neuropsychological testing, and custodial care services for established patients.

They have also finalized the decision that direct supervision in telehealth visits can be provided with interactive audio and video technology through the end of the year until December 2021.

CPT Code	Services	Description
77427	Radiation management	It is reported once for every five fractions or treatment sessions regardless of the actual time period in which the services are furnished. The services need not be furnished on consecutive days.
90853	Group psychotherapy	Group psychotherapy including interpersonal interactions and support with several patients; typically 45 to 60 minutes in length.
90953	End-stage renal disease, one visit per month, ages 2 and younger	End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, etc.
90959	End-stage renal disease, one visit per month, ages 12-19	End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth
90962	End-stage renal disease, one visit per month, ages 20 and older	With 1 face-to-face physician visit per month
92057	Speech/hearing therapy	Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual
92521	Evaluation of speech fluency	Evaluation of speech fluency (e.g., stuttering, cluttering)
92522	Evaluation speech production	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)
92523	Speech sound language comprehension	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)
92524	Behavioral quality voice analysis	Behavioral and qualitative analysis of voice and resonance.
96130	Psychological test Evaluation Phys/qhp 1st	Psychological testing evaluation services by a physician or other qualified healthcare professional, including the integration of patient data, interpretation of standardized test results and clinical data
96131	Psychological test evaluation phys/qhp ea	Providers should now use CPT code 96130 to bill for the first hour of psychological testing evaluation services and 96131 for each additional hour
96132	Neuropsychological testing evaluation phys/qhp 1st	Neuropsychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
96133	Neuropsychological testing evaluation phys/qhp ea	The first hour of neuropsychological evaluation is billed using 96132 and each additional hour needed to complete the service is billed with code 96133
96136	Psychological and neurological testing phy/qhp 1s	Psychological or neuropsychological test administration/scoring by physician or other qualified healthcare professional, two or more tests, any method; first 30 minutes
96137	Psychological and neurological testing phy/qhp ea	Similar to 96136. This code is used for each additional hour.
96138	Psychological and neurological tech phy/qhp ea	Psychological or neuropsychological test administration/scoring by technician, two or more tests, any method; first 30 minutes
96139	Psychological and neurological testing tech ea	Similar to 96138.
97110	Therapeutic exercises	Foundational, occupational therapy exercises that are designed to improve a patient’s strength, range of motion, endurance, or flexibility.
97112	Neuromuscular re-education	Specific exercises or activities performed and for what purpose, neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, and/or posture.
97116	Gait training therapy	Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing).
97161	Physical therapy evaluation	Physical therapy evaluation of low complexity, 20 min
97162	Physical therapy evaluation	Physical therapy evaluation moderate complexity, 30 min
97163	Physical therapy evaluation	Physical therapy evaluation moderate complexity, 30 min
97164	Physical therapy evaluation	Physical therapy re-evaluation establish plan care
97165	Occupational therapy evaluation	Occupational therapy evaluation low complexity, 30 min
97166	Occupational therapy evaluation	Occupational therapy evaluation moderate complexity, 45 min
97167	Occupational therapy evaluation	Occupational therapy evaluation high complexity, 60 min
97168	Occupational therapy	Occupational therapy re-evaluation establish plan care
97535	Self-care management training	Direct one-on-one supervision and instruction regarding activities of daily living related to the patient’s health and hygiene.
97750	Physical performance test	Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.
97755	Assistive technology assessment	This procedure is used by the provider to assess the suitability and benefits of technological interfaces that will help restore, augment, or compensate for existing functional ability in the patient.
97760	Orthotic management and training 1st en	Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes.
97761	Prosthetic training 1st enc	Prosthetic training, upper and/or lower extremities, initial prosthetic encounter, each 15 minutes
99217	Observation care discharge	This code is used to report all services provided to a patient discharged from outpatient hospital “observation status” if the discharge is on a date other than the initial date of “observation status
99218	Initial observation care	The first visit of the patient’s admission for outpatient hospital observation care by the Admitting/Supervising Physician or Other Qualified Healthcare Professional. Typically, 30 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99219	Initial observation care	Similar to 99218 but, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99220	Initial observation care	Similar to 99218 but, 70 minutes are spent at the bedside and on the patient’s hospital floor or unit.
99221	Initial hospital care	Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician.
99222	Initial hospital care	Similar to 99221
99223	Initial hospital care	Similar to 99221
99234	Observation/hospital same date	Observation or inpatient care, are used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.
99235	Observation/hospital same date	Observation or inpatient care is used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.
99236	Observation/hospital same date	Observation or inpatient care is used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.
99238	Hospital discharge day	Used when time spent is less than 30 minutes on the discharge process in face-to-face evaluation.
99239	Hospital discharge day	Used when time spent is greater than 30 minutes on the discharge process in face-to-face evaluation.
99281	Emergency department visit	Requires these 3 key components: A problem-focused history; A problem-focused examination; and Straightforward medical decision-making. Usually, the presenting problem(s) are self-limited or minor.
99282	Emergency department visit	Requires these 3 key components: An expanded problem-focused history; An expanded problem-focused examination; and Medical decision-making of low complexity. Usually, the presenting problem(s) are of low to moderate severity.
99283	Emergency department visit	Requires these 3 key components: An expanded problem-focused history; An expanded problem-focused examination; and Medical decision-making of moderate complexity. Usually, the presenting problem(s) are of moderate severity.
99284	Emergency department visit	Requires these 3 key components: A detailed history; A detailed examination; and Medical decision-making of moderate complexity. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.
99285	Emergency department visit	Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.
99291	Critical care first hour	It is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date
99292	Critical care additional 30 mins	Code 99292 (critical care, each additional 30 minutes) is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care.
99304	Nursing facility care initial	The problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99305	Nursing facility care initial	The problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99306	Nursing facility care initial	The problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit.
99315	Nursing facility discharge day	99315 is for discharge day management 30 minutes or less
99316	Nursing facility discharge day	This code is for discharge day management over 30 minutes
99327	Domiciliary or rest home visit new patient	Domiciliary or rest home visit for the evaluation and management of a new patient. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99328	Domiciliary or rest home visit new patient	Code used for Evaluation and Management / Domiciliary, rest home (boarding home) or custodial care services. The general guidance for this code is that it is used for new patient assisted living visits, typically 75 minutes.
99334	Domiciliary or rest home visit established patient	This code 99334 is used to reflect the domiciliary or rest home visit for the E/M of an established patient
99335	Domiciliary or rest home visit established patient	Similar to 99334
99336	Domiciliary or rest home visit established patient	Similar to 99334
99337	Domiciliary or rest home visit established patient	Domiciliary or rest home visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family
99341	Home visit new patient	Home services are 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. Level 1 new patient home visit.
99342	Home visit new patient	Home services are 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. Level 2 new patient home visit.
99343	Home visit new patient	Home services are 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. Level 3 new patient home visit.
99344	Home visit new patient	Home services are 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. Level 4 new patient home visit.
99345	Home visit new patient	Home services are 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.Level 5 new patient home visit.
99347	Home visit established patient	Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components. A problem-focused interval history; a problem-focused examination; and straightforward medical decision making. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99348	Home visit established patient	Similar to CPT Code 99348. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99349	Home visit established patient	Similar to CPT Code 99348. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99350	Home visit established patient	Similar to CPT Code 99348. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99468	Neonatal critical care initial	Services of directing the inpatient care of a critically ill neonate or infant 28 days or younger.
99469	Neonatal critical care initial	Services of directing the inpatient care of a critically ill neonate or infant 28 days or younger.
99471	Pediatric critical care initial	Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age
99472	Pediatric critical care initial	Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age
99473	Self-measurement of blood pressure at home education/training	Code 99473 represents the work of training the patient and calibrating the device,
99475	Pediatric critical care ages 2-5 initial	Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age
99476	Pediatric critical care ages 2-5 subsequent	Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age
99477	Initial day of hospital care for neonatal care	Initial hospital care of the neonate (28 days or younger) who is not critically ill but requires intensive observation, frequent interventions, and other intensive care services.
99478	Ic low-birthweight infant	Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant( < 1500 gm)
99479	Ic low-birthweight infant < 1500-2500 g subsequent	Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant( 1500 gm-2500g)
99480	Ic infant pbw 2501-5000 g subsequent	Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant(2501g-5000g)
99483	Assessment and care plan cognitive impairment	Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home

The ongoing pandemic has resulted in an increased workload for healthcare providers across the country. Incorporating telehealth software into an existing practice can allow providers to virtually connect with patients. This can relieve the strain on practice while introducing an additional revenue stream.

HealthViewX Telehealth/Telemedicine Platform helps health systems to align clinical, financial, and operational goals by providing high-quality remote care and enhancing patient-physician collaborations.

References: https://www.beckershospitalreview.com/telehealth/cms-adds-85-more-medicare-services-covered-under-telehealth.html

Earn from Medicare’s Chronic Care Management Program! CCM made simple!

Chronic Care Management Services are delivered to Medicare beneficiaries with two or more chronic conditions with a goal of improving health and quality of care for high-need patients. As population ages, FQHCs, RHCs, ACOs, Hospitals, individual practitioners, etc. face the daunting challenge of improving quality of care for chronically ill patients while containing costs.

The Centers for Medicare and Medicaid Services (CMS) says about 93% of total Medicare spending is on beneficiaries with multiple chronic conditions. Research has shown that highly fragmented care for Medicare beneficiaries with multiple chronic conditions are more likely to present in emergency rooms, and be admitted than others.

In spite of the need for proactive care for Chronic Care Management Patients, a lot of the providers are still underutilizing this benefit. There are several reasons why providers like FQHCs, RHCs, ACOs, Hospitals, individual practitioners, etc. have chosen to leave it on the table.

Complicated Process:

There are several rules physicians and practices have to follow in order to qualify for CCM reimbursement. CMS has set rules right from enrolling Medicare patients up to the necessary documents that have to be furnished for CCM reimbursement. Other mandatory requirements include providers offering CCM service, should have access to patient’s health records, provide 24/7 access to care, provide care plans, and patients be able to reach providers to meet urgent care needs.

Time Consuming and involves additional costs:

Many providers feel offering CCM service is a time-consuming effort, and requires additional staffing. They find it difficult to document each of these and also provide quality care for their patients. Providers feel there is an increased administrative burden to managing and tracking CCM services, and it also involves additional cost.

Patients Consent:

Providers must identify Medicare eligible patients, explain CCM services and get consent to enroll the patient and start the service. Providers must explain the required information in detail where the patient can either accept or decline the service.

Wait and See Approach:

Providers want to first see if the approach is effective before deciding to opt for it. Many providers and physicians wait to see if other providers who opted to provide the service have success with reimbursement before committing to participation in the program.

HealthViewX makes Chronic Care Management process easier with the below features and makes reimbursement simple:

Automated Documentation for CMS Auditing

HealthViewX automates and streamlines the end-to-end CCM process. Integrates with softphones to accurately record the time spent on each call. It easily helps generate reports as per CMS requirements.

Comprehensive Care Plan

Structured care plans are essential to help organize coordination of actions for proper patient progression and self-management. The solution helps create condition-specific, personalized and comprehensive care plans for each patient including tasks and goals for both the patient and care coordinator track for better care coordination. Simplifies and streamlines workflow to guide tele-nurses in creating care plans.

HIPAA Compliant

HealthViewX CCM follows HIPAA compliance requirements and guidelines. The solution lets you define the access, have user-specific access conditions, and provides secure access to patient records.

Analytics and Dashboard

Gives detailed actionable insights for better care coordination. Data can be visually represented and users can gather detailed information by clicking the desired data. The dashboard also displays the follow-up reminders that can be set-up by the user against each patient.

Take this simple step to improve health outcomes and reduce costs for patients with multiple chronic care conditions.

Schedule a demo and talk to HealthViewX Solution experts today to discuss the CCM solution. Or simply outsource your CCM services. HealthViewX also provides end-to-end CCM services through our network of seasoned RNs and CMAs that enable you to increase your monthly reimbursements without incurring any additional cost of hiring additional staff or investing in technology solutions.

Understanding the scope of Chronic Care Management and what is required to make it profitable

Approximately 71% of the total healthcare spend in the United States is associated with care for Americans with more than one chronic condition. Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93% of total Medicare spending.

It is said that a large percentage of these expenses are associated with acute care and emergency visits that could be prevented by earlier intervention. Patients who have multiple chronic conditions require ongoing medical attention. Putting further emphasis on health programs with an eye towards preventing and controlling chronic disease is one of the ways to address such costs.

The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals.

What Physicians need to understand?

Medicare’s Chronic Care Management program has a primary clinical goal which is improving the health of Medicare patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and who are at significant risk of death, acute exacerbation/decompensation, or functional decline. In addition to understanding the service-level parameters, pay levels, CCM codes.

PCP’s and other health organizations who provide CCM services need to understand how to effectively bill for CCM in order to profitably achieve that goal.

Some of the basic preconditions that providers must satisfy are:

the provider is required to complete an initial face-to-face visit
obtain verbal or written consent from the patient, and develop a comprehensive care plan in the electronic health record
provide 24/7 access to care
use a certified EHR to aggregate all patient health information
establish continuity through a designated care team member who works with the patient to implement a dynamic plan that spells out the patient’s key prevention and treatment goals and strategies

Who all can provide CCM services?

Additionally to physician offices, Chronic Care Management Services can be provided by

Federally Qualified Health Centers
Rural Health Clinics
Critical Access Hospitals

And the following healthcare professionals can bill for CCM services

Physicians
Physician Assistants
Nurse Practitioners
Certified Nurse-Midwives
Clinical Nurse Specialists

Non-physicians must legally be authorized and qualified to provide CCM in the state in which the services are furnished.

Why provide Chronic Care Management Services?

It benefits both providers and patients. Patients will receive better-coordinated care thereby preventing hospitalization and re-admissions. Providers will not only receive payments for providing care but also improve practice efficiency, compliance, patient satisfaction, and health outcomes. Practices, large providers, and health systems can add net new recurring monthly revenue.

How do physicians and other providers document the CCM services that are provided?

Some practices do the tracking manually, while some of the practices have CCM documentation built into their EHR’s. Other practices implement specialized CCM software to track time and ensure all the CCM requirements are met. Some of the CCM software has the ability to track not only the documentation but also send reminders or notifications to the patient, provider and other healthcare professionals involved in patient care.

How to make CCM profitable?

Chronic care management requires 24/7 access to care. Practices take different approaches to meet this requirement to provide better care coordination. Some practices hire additional staff and some opt for a solution to automate the end-to-end process to cut down on additional staff expenses. Considering healthcare IT will not only cut down on additional expenses but will also make CCM more effective and efficient.

Talk to HealthViewX solution experts to understand more about HealthViewX CCM solution and make your CCM profitable.