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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

Increasing Patient Retention and Revenue with Referral Management

The ratio between the number of dentists and the population in the USA is 61:100000. More than one in five (21.3%) said that they had not visited the dentist in the last few years. One of the top reasons adults cite for avoiding the dentist is the inability to find a convenient location or appointment time. Specifically, 19% of adults had not visited the dentist in a few years because they cannot find a convenient location or appointment time. As a dentist or dental practice manager, it is crucial to not just manage existing patients but to account for lost opportunity and plan to improve patient experience, especially with appointment schedule and completion. This will result in an increase in the number of patients visiting dental centers.

Dental centers/groups can begin by leveraging technology to manage the patient referral workflow. Inbound patient referrals having dental issues usually have accompanying ailments such as diabetes or accidental injuries. A seamless experience from appointment scheduling to treatment completion will positively impact patient satisfaction and the volume of inbound patient referrals.

Existing Patient Referral Management Workflow in a Dental Center

Did you know? In a year, 15 billion faxes are sent out with patient referral information in the USA. Practices receive referrals through fax, online forms, direct messaging, email, virtual print, direct walk-ins, and other channels. A typical dental center or dental group is a high inbound referral setup. Dental centers receive large volumes of referrals weekly (ranging from 50 per week to even several hundred per week) depending on the number of patients visiting the center and the number of clinics sending referrals to them. An effective referral management solution will help manage small or big volumes of referrals by reducing manual tasks and using automation and structure where possible.

Dental centers usually have a dedicated team of referral coordinators who receive, accept, and process the referral requests. These referral coordinators manually key in the necessary details into an EMR/ EHR system and create a referral. The time spent by a referral coordinator in a completely manual process can be reduced by using technology. Productivity and efficiency are increased by introducing technology to aid the process. It results in piling up requests that are not yet processed. When the referral coordinator does not have the required information to process the referral, he has to contact the referring provider. This further incurs time and results in a slow referral processing rate. This, in turn, has a negative impact on patient experience. Hence, patient referral leakage also becomes imminent.

Consequences of a Slow Referral Network

Revenue loss is a direct result of the untimely processing of referrals
Providers stop referring to the center thereby harming its reputation
Waiting times and appointment scheduling process affects patients requiring critical and immediate attention

Challenges Faced by a Dental Center

Multiple Referral Channels: For the specialist/imaging center that receives referrals, face more difficulties than the referring provider. They receive referrals through various channels like fax, email, direct message, website, user-filled forms, etc. Managing and tracking all of it manually is a tedious task. The chances of missing out on a referral are high.
Appointment Scheduling and Patient No-Show Rates: After receiving the referral, the specialist/imaging center schedules appointments with the patient. In some cases, the patients are not notified clearly about the appointment. When patients do not show up, it is difficult for the specialist/imaging center to track. It results in revenue loss and patient dissatisfaction.

Let us review a typical referral process to elaborate on the challenges faced by the dental centers.

Patient Visits the PCP

Andrews met with an accident recently. He met his PCP, Dr. John, immediately as he was experiencing pain in his jaw. After examining him, Dr. John wanted him to consult a dentist. The doctor then initiated the referral.

PCP Initiates the Referral

John created a referral in his EMR. He did not have time to do the insurance pre-authorization so he left it to Andrews. He then found a dentist and gave him referral information verbally. Now when he met the specialist, Andrews had to again elaborate on his condition and problems to him. This is time-consuming for the specialist as he wastes time on the same information twice.

Specialist Requires More Information

The specialist, Dr. James, is a famous dentist in the locality. After receiving the referral, he schedules an appointment with Andrews. After the appointment, Dr. James wants more information about the patient’s history and diagnostic reports. Now, he has to wait for the PCP, Dr. John, to send him the relevant information.

No Tracking System for Referrals

As Dr. James is a famous dentist in the locality, he receives numerous referrals in a day. There is no tracking system for him to know how many referrals he received, how many were processed, in what status each referral is in, etc. So it is difficult for Dr. James to understand the analytics of his specialty.

Overcome your challenges with HealthViewX Patient Referral Management Solution:

With a Referral Management solution like HealthViewX, you can eliminate all your challenges and achieve referral loop closures in an efficient way. Here are some of the key features that will help you transform your referral process:

Multi-Channel Referral Consolidation

The HealthViewX solution can capture fax, phone, email, online form referrals or any other referrals in a single interface. It makes it easy to monitor and manage all channels of referrals in a single queue.

Patient Coordination Framework

After finding the receiving provider, the referral coordinator refers the patient. When the receiving provider receives the referral, the provider will get notified of the referral. Even the patient will be notified of the referral. The receiving provider can schedule appointments based on the patient’s comfort. This will cut down patient no-show rates.

Referral Tracking

HealthViewX gives a clear picture of how a referral has progressed with the help of a timeline view. Every referral has a status that conveys in which stage the referral is in. With the help of a customizable dashboard, the exact number of referrals waiting to be processed can be identified easily.

New Referral Channel

HealthViewX Referral Management solution supports a new channel for sending and receiving referrals. This is called the desktop application. Sources like email, website, direct message, fax, etc are not secure and difficult to handle. On the other hand, desktop applications are a secure source for sending and receiving referrals. Also, documents can be attached and sent as a referral.

Referral Data Consolidation

It has options for printing the consolidated data about the referrals and the referral history of any patient as a hard copy at any time in pdf/excel.

Secure Data Management

HealthViewX Patient Referral Management is HIPAA compliant. It manages all patient-related documents securely.

Referral Analytics

Helps in tracking the number of referrals and gives complete information about the referrals processed, missed, scheduled, etc. with the help of a Referral Data-centric Dashboard.

Talk to us to understand how to streamline and automate the end-to-end referral cycle without disturbing your existing EMR setup.

2021 CPT Codes by the CMS for Medicare Extension Care Management Programs

Chronic Care Management:

The chronic care management program was virtually untouched by the 2021 Final Rule from CMS. There are three main CPT codes and two add-on CPT codes in 2021 that may be billed by primary care providers for CCM services.

Requirements for CCM:

Non-Complex CCM:

Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
Patient consent (verbal or signed)
Personalized care plan in a certified EHR and a copy provided to the patient
24/7 patient access to a member of the care team for urgent needs
Enhanced non-face-to-face communication between patient and care team
Management of care transitions
At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by a physician or other qualified healthcare professional
CCM services provided by a physician or other qualified healthcare professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management activities

Complex CCM:

Shares common required service elements with CCM but has different requirements for:

Amount of clinical staff service time provided (at least 60 minutes)
The complexity of medical decision-making involved (moderate to high complexity)

CPT Reimbursement Codes for CCM Service:

Non-complex CCM:

CPT Code 99490– This code requires that patients must have two or more chronic conditions, as well as documented consent to enroll in the program AND receive at least 20 minutes of CCM services from clinical staff within a given month. A personalized care plan, which shows an assessment of all patient factors and identifies gaps and barriers to be addressed, is also required. Reimbursement Rates – CPT Code 99490 – $42/patient/month.
CPT Code 99439 (formerly G2058) -This code allows providers to bill for each additional 20 minutes spent for Basic CCM services in a given month, up to 2 times. For example, if CCM services were provided for at least 40 minutes with a patient in a given month that was not Complex, 99490 ($42) and 99439 ($38) would be billed together for that month. Reimbursement Rates – CPT Code 99439 (formerly G2058) – $38/patient/month.

Complex CCM:

CPT code 99487– This code has a higher rate of reimbursement than the Basic CCM CPT code. To bill using this code requires moderate or high complexity in medical decision making AND acknowledgment by both patient & provider of an acute exacerbation (generally defined as a sudden worsening of a patient’s condition that necessitates additional time and resources). The patient must receive at least 60 minutes of services from clinical staff within a given month to bill for this code. Reimbursement Rates – CPT Code 99487 – $93/patient/month.
CPT code 99489 – The same as with the Basic Chronic Care Management code, the Complex Chronic Care Management code also has an add-on CPT code to cover time spent beyond 60 minutes. It allows for billing for each additional 30 minutes spent for Complex CCM services within a given month. Reimbursement Rates – CPT Code 99489 – $45/patient/month.

Transitional Care Management:

Transitional Care Management (TCM) services address the hand-off period between the inpatient and community settings. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

Requirements for TCM:

Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via the telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision-making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
Obtain and review discharge information.
Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments.
Educate the beneficiary, family member, caregiver, and/or guardian.
Establish or reestablish referrals with community providers and services, if necessary.
Assist in scheduling follow-up visits with providers and services, if necessary.

CPT Reimbursement Codes for TCM Service:

CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge. Reimbursement rate – $175.76/patient/month.
CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge. Reimbursement rate – $237.11/patient/month.

Allowed reported services alongside TCM services include,

Prolonged services without direct patient contact (99358-99359);
Home and outpatient international normalized ratio (INR) monitoring (93792-93793);
End-stage renal disease (ESRD) services for patients ages 20 years and older (90960-90962, 90966, or 90970);
Interpretation of physiological data (99091); and
Care plan oversight (G0181-G0182).

Remote Patient Monitoring:

RPM involves the collection and analysis of patient physiologic data that are used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition.

Requirements for RPM:

To qualify for CMS reimbursements for utilizing the RPM services efficiently, the service providers and hospitals need to ensure the following:

Medicare part B patients are imposed 20% of copayment (renouncing the copayments regularly can trigger penalties under the Federal Civil Monetary Penalties Law and also the Anti-Kickback Statute)
Patients must take the remote monitoring services and are required to monitor for a minimum of 16 days to be applicable for a billing period.
The RPM services must be ordered by skilled physicians or other qualified healthcare experts.
Data must be wirelessly synced for proper evaluation, analysis, and treatment.

CPT Reimbursement Codes for RPM Service:

CPT code 99453 – It is a one-time practice expense reimbursing for the setup and patient education on RPM equipment. This code covers the initial setup of devices, training and education on the use of monitoring equipment, and any services needed to enroll the patient on-site. Reimbursement rate – $18.77/patient/month.
CPT code 99454 – This code covers the supply and provisioning of devices used for RPM programs, and the code is billable only once in a 30-day billing period. Reimbursement rate – $64.44/patient/month.
CPT code 99457 – This code covers the direct monthly expense for the remote monitoring of physiologic data as part of the patient’s treatment management services. To receive reimbursement, the physician, QHP or other clinical staff must provide RPM treatment management services for at least 20 minutes per month. Reimbursement rate – $51.61 (non-facility); $32.84 (facility) /patient/month.
CPT code 99458 – This code is an add-on code for CPT Code 99457 and cannot be billed as a standalone code. This code can be utilized for each additional 20 minutes of remote monitoring and treatment management services provided. Reimbursement rate – $42.22 (non-facility); $32.84 (facility) /patient/month.

Principal Care Management:

PCM codes are intended to cover services for patients with only one complex chronic condition that requires management by a specialist. Like other chronic care management (CCM) codes (chronic care management, transitional care management), the PCM codes are intended to reimburse physicians for the additional work they do to take care of high-risk, complex patients. This includes the extra time and work required for medication adjustments, creating a care plan, patient follow-up, and more.

Requirements for PCM:

One complex chronic condition lasting at least 3 months, which is the focus of the care plan,
The condition is of sufficient severity to place the patient at risk of hospitalization or has been the cause of recent hospitalization,
The condition requires development or revision of a disease-specific care plan,
The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities

CPT Reimbursement Codes for PCM Service:

CPT Code G2064 – requires 30 minutes of provider (allergist, NP, PA) time each calendar month to care for the patient. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $52/patient/month.
CPT Code G2065 – requires 30 minutes of clinical staff time directed by a provider each calendar month for patient care. Provider supervision does not require the provider to be onsite while clinical staff performs PCM services. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $22/patient/month.

Annual Wellness Visit:

The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical.

Requirements for AWV:

For G0438 (initial visit),

Billable for the first AWV only.
- Patients are eligible after the first 12 months of Medicare coverage.
- For services within the first 12 months, conduct the Initial Preventive Physical Exam (IPPE), also referred to as the Welcome to Medicare Visit (G0402).
The patient must not have received an IPPE within the past 12 months.
Administer a Health Risk Assessment (HRA) that includes, at a minimum: demographic data, self-assessment of health status, psychosocial and behavioral risks, and activities of daily living (ADLs), instrumental ADLs including but not limited to shopping, housekeeping, managing own medications, and handling finances.
Establish the patient’s medical and family history.
Establish a list of current physicians and providers that are regularly involved in the medical care of the patient.
Obtain blood pressure, height, weight, body mass index or waist circumference, and other measurements, as deemed appropriate.
Assess a patient’s cognitive function.
Review risk factors for depression, including current or past experiences with depression or mood disorders.
Review patient’s functional ability and safety based on direct observation, or the use of appropriate screening questions.
Establish a written screening schedule for the individual, such as a checklist for the next 5 to 10 years based on appropriate recommendations.
Establish a list of risk factors and conditions for primary, secondary, or tertiary intervention.
Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
At the patient’s discretion, furnish advance care planning services.

For G0439 (subsequent visit),

Billable for subsequent AWV.
The patient cannot have had a prior AWV in the past 12 months.
Update the HRA.
Update the patient’s medical and family history.
Update the current physicians and providers that are regularly involved in providing the medical care to the patient, as developed during the initial AWV.
Obtain blood pressure, weight (or waist circumference, if appropriate), and other measurements, as deemed appropriate.
Assess a patient’s cognitive function.
Update the written screening schedule checklist established in the initial AWV.
Update the list of risk factors and conditions for which primary, secondary, and tertiary interventions are recommended or underway.
Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
At the patient’s discretion, the subsequent AWV may also include advance care planning services.

CPT Reimbursement Codes for AWV Service:

The four CPT codes used to report AWV services are,

G0402 Initial Preventive Physical Exam – This code is used for patients visiting within 12 months after enrolling in Medicare.
G0438 Initial Visit – This visit is eligible within 11 calendar months from the date of IPPE.
G0439 Subsequent Visit – This code is used for every subsequent visit. Patients are eligible for this benefit every year after their Initial AWV.
CPT 99497/99498 – Patients are eligible for an Advance Care Planning (ACP) at any time. But if performed during an AWV, the patient has no copay.

Behavioral Health Integration:

Integrating behavioral health care with primary care (“behavioral health integration” or “BHI”) is an effective strategy for improving outcomes for millions of Americans with behavioral health conditions. Medicare makes separate payments to physicians and non-physician practitioners for BHI services they furnish to beneficiaries over a calendar month service period.

Requirements for BHI:

Any mental or behavioral health condition being treated by the billing practitioner, including substance use disorders, that, in the clinical judgment of the billing practitioner, warrants BHI services.
The diagnosis or diagnoses could be either pre-existing or made by the billing practitioner and may be refined over time.

CPT Reimbursement Codes for BHI Service:

The CPT code used to report BHI services is,

CPT Code 99494 – Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional.

References:

https://signallamphealth.com/2021-medicare-cms-chronic-care-management-ccm-cpt-code-updates/

https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1

https://college.acaai.org/new-principal-care-management-cpt-codes/#:~:text=G2064%20requires%2030%20minutes%20of,is%20%2452%2Fpatient%2Fmonth

https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/transitional-care-management.htm

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf

Improving Patient Care Through Technology Orchestration

As healthcare shifts towards a more patient-centric approach, health providers across the world are looking for innovative ways to enhance the patient care journey. The infusion of software solutions into the healthcare industry has helped providers improve the overall patient experience. One of these solutions is Care Orchestration, a method that uses Information Technology (IT) to improve the care journey. Care Orchestration can be defined as the coordination of many complex computer systems, servers, and applications in a way that enhances the care journey. In a clinical setting, Orchestration allows for a simplification of patient workflows and an overall improvement in efficiency. Care Orchestration helps healthcare providers streamline their existing care journey by identifying and addressing their current inefficiencies.

Care Orchestration and Value-Based Care

Care Orchestration is an instrumental asset for health systems that seek to adopt a value-based outlook. This system is a polar opposite from the traditional fee-for-service view as value-based care rewards health systems that can improve patient experiences and outcomes. Orchestration allows clinics to achieve this by streamlining the entire patient workflow. Patients are not met with any unwanted obstacles at any point in their care journey. The data processing efficiency of orchestration tools increases the speed at which physicians can treat and diagnose patients.

How Artificial Intelligence works with Orchestration

Artificial Intelligence (AI) has become increasingly popular as a reliable solution for modern health tech issues. AI is well known for its operational efficiency thanks to its command of complex human attributes such as comprehension, interpretation, and analysis. It becomes quite evident that AI and Orchestration are similar concepts by reviewing their capabilities. In fact, many health systems employ a software system that uses AI and Orchestration together. The difference between these concepts lies in the scale of their abilities. AI is generally used for replacing human services by introducing automation for individual tasks. This is in contrast with Orchestration which generally involves coordination of complex, multi-step procedures. Using AI and Orchestration together results in an automated workflow that requires little human input. This partnership is extremely efficient due to the ability of AI to process millions of data points in a matter of seconds. Orchestration is also quite productive as it allows AI to automate over a series of procedures rather than just one action.

Benefits of Orchestration

The introduction of Orchestration into a clinical setting has brought many positive results for both care providers and patients. Here are some of the primary benefits:

Smoother Care Journey: Having a straightforward care journey greatly benefits patients as their once tiresome and time-consuming clinical visits are now simple and convenient. By displaying command of complex methods, Orchestration ensures that there are no gaps in the care journey. Patients are expedited through the care journey in an efficient manner, enhancing the patient outcomes and improving the overall experience.
Increased Operational Efficiency: Care Orchestration helps health systems simplify their workflow processes while maximizing the available resources. Effective orchestration performs tasks such as data organization in a fraction of the time that humans would take. This means Clinical staff can perform their duties more effectively while also gaining the ability to spend more time with patients.
Increased Profits: Another operational benefit of Orchestration is its ability to positively impact a clinic’s bottom line. The aforementioned efficiency allows clinics to expand their capacity and serve more patients. This allows for an increase in revenue without compromising on quality of care. Clinics are simultaneously able to lower their costs as orchestration prevents expensive rifts in operation such as referral leakage.

Care Orchestration is extremely powerful with the potential to transform health systems across the country. The extensive multi-faceted approach in improving the experience of both patients and care providers separates orchestration from other IT solutions.

Talk to us to understand more about the advancements in the healthcare industry and we will guide you to achieve our common goal “Quality Care for All” seamlessly.

The Evolution Of The Health Tech: Positive Change Through Interoperable Solutions

The American Healthcare Industry has experienced many large-scale changes in the past few decades. This timeframe has afforded us many drastic reforms in the industry such as the Affordable Care Act (ACA) or the widespread shift towards Value-Based Care. However, the most noteworthy and significant change is the gradual adoption of software solutions into the healthcare industry. The digitization of healthcare has brought numerous benefits to healthcare organizations that are able to streamline their day-to-day operations. More importantly, these solutions have made life easier for care providers and patients by simplifying the delivery of care. In order for these complex systems to operate, they need to display competency in Interoperability.

How Interoperability Ties It All Together

Interoperability in the context of healthcare refers to the use of many complex systems and information technology (IT) to exchange and interpret health-based data. As many software systems were designed for specific tasks, the transfer of data between different systems emerged as a significant challenge. Interoperability allowed for different computer systems that operate on different platforms to interact with each other. This gave health organizations the ability to employ multiple systems for their varying needs. At the foundational level, interoperability is present in roughly 75% of health systems in the US. The incorporation of more advanced levels allows organizations to expand the scale of their services.

How Technology is Combatting COVID-19

The COVID-19 Pandemic has proved to be a challenging obstacle for the healthcare industry. While the pandemic continues to test the industry’s existing abilities, the prevalence of computer systems currently in use have helped in the fight to control COVID-19. The use of virtual health services has skyrocketed since the outbreak as clinics across the country shift their focus to COVID-19. Patients are able to access health services like routine check-ups from their tablet or computer. The significance of this service is that it ensures patients with chronic conditions can receive medical services without the risk of being infected with COVID-19. It also helps clinics establish stable cash flow and make up for revenue shortfall due to the pandemic.

Examples of Interoperable Health Tech Solutions:

Telehealth

Telehealth involves the transfer of healthcare services through a telecommunications platform. While the primary use of telehealth is for virtual conferencing between patients and physicians, it is also used for monitoring and educating patients. The most popular form of telehealth is video conferencing where patients and physicians can perform most tasks required in a typical check-up. According to the American Hospital Organization (AHA), 3 out of every 4 hospitals offer some form of telehealth service. Telehealth has proven to be a valuable tool in the fight against COVID-19, while also eliminating long wait times and nonessential clinical visits. Telehealth must be interoperable with other platforms in order to share Electronic Health Records (EMR). Reviewing these records is crucial for physicians who are deciding the next course of action for a patient.

Remote Patient Monitoring

Remote Physiological Monitoring (RPM) uses real-time technology to collect vital parameters such as heart rate, blood pressure, weight, or any other relevant health-based measure. These devices are worn by patients to track the parameters of their health while simultaneously sending the results to a qualified health professional. This professional can analyze the information and intervene if there is any abnormal data. These gadgets have been extremely helpful for chronic care patients who can avoid the hassle of regular clinical visits. Clinics who effectively use these devices can significantly reduce the number of readmissions, which costs the industry over $41 billion a year. Interoperability is crucial in the RPM care delivery as data must be transferred from the patient’s device to the health system without any errors.

Workflow and Referral Management

The goal of Workflow Management is to streamline the patient workflow by eliminating inefficiencies in the process. Tech solutions such as Smart Rooming help nurses room the patient and transfer the responsibility of care in a time-efficient manner. Referral Management is also an extremely crucial part of clinical operations. Referral Leakage, which occurs when a patient’s Referral loop is not closed, costs the industry millions of dollars a year. Interoperable platforms would transfer information from the physician to the specialist in a timely manner and without any gaps.

Artificial Intelligence and Machine Learning

While still extremely developmental in nature Artificial Intelligence (AI) and Machine Learning (ML) provide a glimpse into the future of healthcare. AI and ML both use machines to perform human activities such as comprehension, interpretation, and analysis. Despite a limited role, they are both currently used for routine activities like streamlining workflows, patient education, diagnosis, and predictive analysis. AI/ML can help health tech innovators attain interoperability by assisting computer systems in receiving and analyzing data.

Primary Benefits

The influx of interoperable systems has revolutionized the healthcare industry. Listed below are the main benefits of these solutions.

Improved Patient Experience: One of the main focuses of these innovative software solutions was to improve the overall experience of patients. The introduction of Telehealth and RPM increases access to healthcare for all patients. Tools such as AI and ML are life-saving as they quickly and accurately diagnose conditions.

Simplifying the Care Journey: In the traditional Care Journey, patients may have to spend an entire day in a clinic while physicians shuttle back and forth to tend to them. Software Solutions have streamlined this process by assisting clinics with scheduling, rooming, and diagnosis. Nurses, Physicians, and Clinical staff can allocate their time more efficiently, resulting in a smoother Care Journey for patients.

Optimal Operational Efficiency: Health Organizations are able to maximize the use of their resources thanks to health tech solutions. Using tools like Referral Management and Care Orchestration allows organizations to streamline patient workflows. This helps them serve more patients without having to expand or increase costs.

Increased Profit: Perhaps the greatest benefit for organizations is the ability to increase clinical profits. Efficient software solutions help organizations identify and eliminate inefficient practices. At the same time, solutions like RPM provide additional revenue streams for clinics with little additional cost. While Interoperable solutions may incur an initial cost, effective development and use of the product will have a positive impact in the long run.

Talk to us to understand more about the advancements in the healthcare industry and we will guide you to achieve our common goal “Quality Care for All” seamlessly.

How Patient Rooming Checklists Streamline the Patient Care Journey

Patient Rooming is the process where nurses greet and familiarize patients with their clinical surroundings before transitioning the responsibility of care to physicians or other health professionals. It is an integral part of the care journey as patients can address any pressing concerns before their doctor or specialist arrives. Despite this, many clinics fail to maximize the patient experience of the rooming process. Long wait times, inefficient use of staff, and the lack of centralized patient records are the primary issues that clinics face when rooming patients. Smart Rooming Checklists can prevent these issues by simplifying the rooming process for patients and nurses.

What are Smart Rooming Checklists?

Smart Rooming Checklists remind Medical Assistants to perform important tasks related to the Rooming of each patient. They contain three sections: Pre-Rooming, Rooming, and the Handoff. Pre-Rooming involves any preparation work that assistants must take part in before the patient arrives. Rooming is the most important section as it requires assistants to greet patients and address any concerns. Finally, the Handoff is when the assistant briefs the physician on any important information in relation to the patient. Each of these sections contains many subsections that detail individual tasks that the assistant is responsible for.

Pre-Rooming Preparation

The first section of the checklist is the Pre-Rooming preparation. This part involves any tasks that the medical assistant would need to perform before meeting with the patient. The medical assistant would start off by Reviewing the Patient’s Medical History. This helps the assistant understand their existing conditions and treatment plan. After this, assistants would review the patient’s recent test/screening results. To finish off the preparation, assistants would take note of any additional relevant information. This could include feedback from past visits. The objective of pre-visit preparation is for assistants to be proactive about the questions or concerns the patients may have. By planning for these in advance, assistants can save time and generate better responses while rooming the patient. Once this section of the checklist is complete, the assistant can approach the patient and begin the formal rooming process.

Rooming

The Rooming section is the most important portion of the checklist as it highlights the tasks that must be completed when interacting with the patient. To maximize rooming efficiency, assistants must ensure that the time from Patient Introduction to the Handoff is minimized without compromising on quality. Assistants can refer to their pre-visit research to streamline this process. Here are the common steps involved in Patient Rooming:

Patient Introduction: Greet the patient in the waiting room and lead them to the appointment room. Ensure that you are engaging with the patient in a warm and welcoming fashion.

Inquire About Appointment Objective: In a kind and compassionate manner, inquire about the patient’s objective of the appointment. Understand why they are there and what they seek to accomplish from the visit. Identify the most high-priority health concerns.

Update Health Records: Add any new conditions or symptoms to the patient’s health record. Be sure that any recent tests or screenings have been indicated on the record.

Address Patient Questions: Encourage patients to be open about any concerns they have about their treatment or condition. Inform the physician of any questions that are relevant to the appointment.

Conduct Patient Screening: Screen the patient using standard protocol to determine any tests or procedures that they will need to undergo. Prepare the patient for any tests that the physician will be performing and if necessary provide them with the appropriate protective gear.

The Handoff

The Handoff occurs when the responsibility of care is transferred from the assistant to the physician. This occurs directly after the Rooming process is complete. Just before the handoff, assistants must take note of the most important takeaways from the Preparation and Rooming process. This can include reaction to treatment, recent test results, or any new concerns. They must then articulate this to the physician in a very direct and brief manner. Once the Handoff is complete, the rooming process is officially over.

Why are Checklists Important?

Smart Rooming checklists can help medical assistants perform their everyday activities in a more efficient manner. By tracking every step of the rooming process, assistants can make sure they don’t forget important tasks. Using this guide will also help them tend to patients faster, which in turn means the clinic can serve more patients and maximize revenue.

Talk to us to understand more about the advancements in the healthcare industry and we will guide you to achieve our common goal “Quality Care for All” seamlessly.

Advantages of CMS changes to Telehealth:

Telehealth services made permanent post-COVID-19:

CPT Code

Services

Description

Existing Patient Referral Management Workflow in a Dental Center

Consequences of a Slow Referral Network

Challenges Faced by a Dental Center

Patient Visits the PCP

PCP Initiates the Referral

Specialist Requires More Information

No Tracking System for Referrals

Overcome your challenges with HealthViewX Patient Referral Management Solution:

Multi-Channel Referral Consolidation

Patient Coordination Framework

Referral Tracking

New Referral Channel

Referral Data Consolidation

Secure Data Management

Referral Analytics

Requirements for CCM:

CPT Reimbursement Codes for CCM Service:

Requirements for TCM:

CPT Reimbursement Codes for TCM Service:

Requirements for RPM:

CPT Reimbursement Codes for RPM Service:

Requirements for PCM:

CPT Reimbursement Codes for PCM Service:

Requirements for AWV:

CPT Reimbursement Codes for AWV Service:

Requirements for BHI:

CPT Reimbursement Codes for BHI Service:

Care Orchestration and Value-Based Care

How Artificial Intelligence works with Orchestration

Benefits of Orchestration

How Interoperability Ties It All Together

How Technology is Combatting COVID-19

Telehealth

Remote Patient Monitoring

Workflow and Referral Management

Artificial Intelligence and Machine Learning

Primary Benefits

What are Smart Rooming Checklists?

Pre-Rooming Preparation

Rooming

The Handoff

Why are Checklists Important?