Chronic Care Management Changes (Coordination of Care)€¦ · CPT Code 99490: Only Until December...

Advanced RHC Billing - 2018

Chronic Care Management Changes (Coordination of Care)

Proposed PFS Changes

Commingling

Negative Payments

Difficult Claim Examples

Background: CCM Services for RHC/FQHC

History – 2015 and 2016

Payment began 1.1.2015 for practitioners billing under the Physician Fee Schedule (PFS).

RHC/FQHCs were eligible CCM providers effective 1.1.2016, under direct supervision.

Payment began 1.1.2016 for RHCs and FQHCs.

CPT 99490 is the only payable code

99490 payment is on the Medicare PFS national non-facility payment rate average.

Rate updated annually and has no geographic adjustment.

The RHC and FQHC face-to-face requirements waived.

Background: CCM Services for RHC/FQHC

Beginning January 1, 2017

RHCs and FQHCs can furnish CCM (and TCM) services under general supervision requirements instead of direct supervision requirements.

Scope Of Service Requirements were revised (initiating visit, electronic care plan, beneficiary consent, etc.), consistent with PFS scope of services changes.

2018 PFS Final Rule

“CMS finalized in the CY 2018 Physician Fee Schedule Finale Rule to revise

payment for care coordination services in RHCS and FQHCs by establishing 2 new G

codes for use by RHCs and FQHCs, effective January 1, 2018.“

1. General Care Management (G0511)

2. Psychiatric Coordination of Care Management (G0512)

Chronic Care Management becomes Care Coordination

For CCM services furnished between January 1, 2016 and December 31, 2017:

CCM services can be billed by adding CPT code 99490 to an RHC or FQHC claim, either alone or with other payable services. Payment is based on the Physician Fee Schedule (PFS) national average non-facility payment rate for CPT code

99490.

CCM services furnished on or after January 1, 2018

CCM services can be billed by adding the general care management G code, G0511, to an RHC or FQHC claim, either alone or with other payable services. Payment is set annually at the average of the national non-facility PFS payment rate for CPT codes 99490 (20 minutes or more of CCM services), 99487 (60 minutes or more of complex CCM services), and 99484 (20 minutes or more of general behavioral health integration services).

G0511: General Care Management Services

G0511: General Care Management Services

billed alone or with other payable services on a RHC or FQHC claim.

This code could only be billed once per month per beneficiary, and could not be billed if other care management services are billed for the same time period.

Payment for G0511 is set at the average of the 3 national non-facility PFS payment rates for the CCM (CPT code 99490 and CPT code 99487) and general BHI (CPT code 99484).

The current payment rate is $61.37 for FY2018.

The rate is updated annually based on the PFS amounts and coinsurance applies.

G0511 Billing Requirements

Initiating Visit:

An Evaluation Management (E/M), Annual Wellness Visit (AWV), or

Initial Preventive Physical Examination (IPPE) visit furnished by a physician, Nurse

Practitioner (NP), Physician Assistants (PA), or Certified Nurse-Midwives (CNM) has

occurred no more than one-year prior to commencing care coordination services. This

would be billed as an RHC or FQHC visit.

Billing Requirements: At least 20 minutes of care coordination services has

been furnished in the calendar month furnished a) under the direction of the RHC

or FQHC physician, NP, PA, or CNM, and b) by an RHC or FQHC practitioner, or

by clinical personnel under general supervision.


Beneficiary Consent: Has been obtained during or after the initiating visit and before provision of care coordination services by RHC or FQHC practitioner or clinical staff can be written or verbal, must be documented in the medical record and includes information:

On the availability of care coordination services and applicable cost-sharing.

That only one practitioner can furnish and be paid for care coordination services during a calendar month.

On the right to stop care coordination services at any time (effective at the end of the calendar month).

Permission to consult with relevant specialists.

G0511 Patient Eligibility

Option A: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, OR

Option B: Any behavioral health or psychiatric condition being treated by the RHC or FQHC practitioner, including substance use disorders, that, in the clinical judgment of the RHC or FQHC practitioner, warrants BHI services.

G0511 Service Requirements

Structured recording of patient health information using Certified EHR 24/7 access to physicians or other qualified health care professionals or clinical staff Comprehensive care management including systematic assessment of the patient’s medical, functional, and psychosocial needs Comprehensive care plan

Care plan information made available electronically (including fax) in a timely manner within and outside the RHC or FQHC

Management of care transitions between and among health care providers and settings, including referrals to other clinicians

Coordination with home- and community-based clinical service providers

Enhanced opportunities for the patient and any caregiver to communicate …through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods (patient portal).

G0511: Option B Service Requirements

For patients meeting the eligibility requirements of Option B, the RHC or FQHC must meet all of the following requirements: Initial assessment or follow-up monitoring, including the use of applicable validated rating scales. Behavioral health care planning in relation to behavioral/psychiatric health

problems. including revision for patients who are not progressing or whose status changes. Facilitating and coordinating treatment (such as psychotherapy, pharmacotherapy,

counseling and/or psychiatric consultation). Continuity of care with a designated member of the care team.


Initiating Visit: Initiating Visit: An E/M, AWV, or IPPE visit furnished by a physician, NP, PA, or CNM has occurred no more than one-year prior to commencing psychiatric CoCM services. This would be billed as an RHC or FQHC visit.

Billing Requirements: At least 70 minutes in the first calendar month, and at least 60 minutes in subsequent calendar months of Psychiatric CoCM services, furnished:

a. under the direction of the RHC or FQHC practitioner, and

b. by an RHC or FQHC practitioner or Behavioral Health Care Manager under general supervision.

G0512: Psychiatric Coordination of Care Management

G0512: Psychiatric Coordination of Care Management

billed alone or with other payable services on a RHC or FQHC claim.

This code could only be billed once per month per beneficiary, and could not be billed if other care management services are billed for the same time period.

Payment for G0512 is set at the average of the 2 national non-facility PFS payment rates for CoCM (CPT code 99492 and CPT code 99493).

The current payment rate is $134.58 for FY2018.

The rate is updated annually based on the PFS amounts and coinsurance applies.

G0512: Patient Eligibility/Care Team

RHC or FQHC Practitioner (physician, NP, PA, or CNM) who: Directs the behavioral health care manager or clinical staff Oversees; the beneficiary’s care, including prescribing medications, providing treatments for

medical conditions, and making referrals to specialty care when needed Remains involved through ongoing oversight, management, collaboration and reassessment Behavioral Health Care Manager: Provides assessment and care management services, including the administration of validated rating

scales; behavioral health care planning in relation to behavioral/psychiatric health problems; including revision for patients who are not progressing or whose status changes.

provision of brief psychosocial interventions; ongoing collaboration with the RHC or FQHC practitioner; maintenance of the registry; acting in consultation with the psychiatric consultant.

Is available to provide services face- to-face with the beneficiary; has a continuous relationship with the patient and a collaborative, integrated relationship with the rest of the care team.

Is available to contact the patient outside of regular RHC or FQHC hours as necessary to conduct the behavioral health care manager’s duties.

G0512: Patient Eligibility/Care Team

Psychiatric Consultant who:

Participates in regular reviews of the clinical status of patients receiving CoCM services;

Advises the RHC or FQHC practitioner regarding diagnosis, options for resolving issues with beneficiary adherence and tolerance of behavioral health treatment; making adjustments to behavioral health treatment for beneficiaries who are not progressing;

managing any negative interactions between beneficiaries’ behavioral health and medical treatments

Facilitate referral for direct provision of psychiatric care when clinically indicated

CPT Code 99490: Only Until December 31, 2017.

Claims with CPT code 99490 for CCM services furnished on or before December 31,2017 will be processed and paid.

Service lines reported with CPT code 99490 will be denied for dates of service on or after January 1, 2018.

CPT Codes 99487, 99484, or 99493

Q11: Will claims with CPT codes 99487, 99484, or 99493 be paid? A11. No. RHCs and FQHCs are required to bill for care management services using G0511 or G0512. Q12. Do coinsurance and deductibles apply to care management services? A12. Coinsurance and deductibles apply to all care management services in RHCs, and coinsurance applies to all care management services in FQHCs.

Proposed Rule 2018

Proposed Revision to Payment Methodology for Care Management Services (TA Presentation 7.25.2018)

Proposed payment methodology for HCPCS code G0511 would be the average of the 4 national non-facility PFS payment rates for

CPT 99490 (20 minutes or more of CCM services)

CPT 99487 (60 minutes or more of complex CCM services)

CPT 99484 (20 minutes or more of BHI services)

CPT 99497 (30 minutes or more of CCM furnished by a physician or other qualified health care professional)

Proposed New Payment

CMS is proposing that, effective January 1, 2019, RHCs receive an additional payment for the costs of communication technology-based services or remote evaluation services that are not already captured in the RHC AIR payment when the requirements for these services are met.

Proposed Requirements

At least 5 minutes of communications-based technology or remote evaluation services.

Furnished by an RHC practitioner. To a patient that has been seen in the RHC within the

previous year.

Proposed Requirements

May be billed when the medical discussion or remote evaluation is for a condition not related to an RHC service provided within the previous 7 days,

Does not lead to an RHC service within the next 24

hours or at the soonest available appointment (since in those situations the services are already paid as part of the RHC AIR)

Proposed Billing and Payment

New Virtual Communications G code for use by RHCs (and FQHCs) only

Payment rate set at the average of the PFS national non-facility payment rates for HCPCS code GVCI1(communication technology-based services) and HCPCS code GRAS1 (remote evaluation services)

Proposed Billing and Payment

RHC would be able to bill the Virtual Communications G-code either alone or with other payable services.

The payment rate for the Virtual Communications G-code

would be updated annually based on the PFS amounts.

Additional Information

Face-to-face billing requirements would be waived.

Coinsurance and deductibles would apply to RHC claims for these services.

Comment Suggestion!

The 60 day comment period; public comments are due no later than 5 p.m. on September 10, 2018.

My suggested comment: eliminate the need to have the patient encounter. This will make the service impossible to manage and bill.

Commingling

90 - Commingling

Commingling refers to the sharing of RHC or FQHC space, staff (employed or contracted), supplies, equipment, and/or other resources with an onsite Medicare Part B or Medicaid fee-for-service practice operated by the same RHC or FQHC physician(s) and/or non-physician(s) practitioners.

40.2 - Hours of Operation

Services furnished at times other than the RHC or FQHC posted hours of operation to Medicare beneficiaries who are RHC or FQHC patients may not be billed to Medicare Part B if the practitioner’s compensation for these services is included in the RHC/FQHC cost report.

(See Section 100 on Commingling).

90 - Commingling

Duplicate Medicare or Medicaid reimbursement (including situations where the RHC or FQHC is unable to distinguish its actual costs from those that are reimbursed on a fee-for-service basis),

Selectively choosing a higher or lower re-imbursement rate for the services.

90 - Commingling

RHC and FQHC practitioners may not furnish or separately bill for RHC or FQHC- covered professional services as a Part B provider in the RHC or FQHC, or in an area outside of the certified RHC or FQHC space such as a treatment room adjacent to the RHC or FQHC, during RHC or FQHC hours of operation.

90 - Commingling

If an RHC or FQHC practitioner furnishes an RHC or FQHC service at the RHC or FQHC during RHC or FQHC hours, the service must be billed as

an RHC or FQHC service.

The service cannot be carved out of the cost report and billed to Part B.

90 - Commingling

If an RHC or FQHC is located in the same building with another entity such as an unaffiliated medical practice, x-ray and lab facility, dental clinic, emergency room, etc., the RHC or FQHC space must be clearly defined.

If the RHC or FQHC leases space to another entity, all costs associated with the leased space must be carved out of the cost report.

90 - Commingling

RHCs and FQHCs that share resources (e.g., waiting room, telephones, receptionist, etc.) with another entity must maintain accurate records to assure that all costs claimed for Medicare reimbursement are only for the RHC or FQHC staff, space, or other resources.

Any shared staff, space, or other resources must be allocated appropriately between RHC or FQHC and non-RHC or non-FQHC usage to avoid duplicate reimbursement.

90 - Commingling

The A/B MAC has the authority to determine acceptable accounting methods for allocation of costs between the RHC or FQHC and another entity.

In some situations, the practitioner’s employment agreement will provide a useful tool to help determine appropriate accounting.

Non-RHC Services

Diagnostic Testing and Lab: Independent

The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter.

The technical component of these tests are billed to the Medicare Part B carrier using the fee-for-service provider number.

All lab services are also billed to the Part B carrier.

Diagnostic Testing and Lab: Provider-Based

The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter.

The technical components for X-Ray, EKG, ultrasounds, etc. are billed to the FI using the parent entity’s billing number.

Lab services are also billed to the FI using the parent entity’s billing number.

Negative Payments

Independent RHC Remit Sample [Negative Payment]

Total Charge: $132.00 Applied to Deductible: $ 115.75 Medicare Take Back: -$32.30 RHC Rate = $ 83.75

Provider-Based RHC Remit Sample [Negative Payment]

Negative Payments: Medicare will take-back the amount applied to Deductible in excess of the RHC AIR.

Reporting Services

Billing Example: Medical Visit plus Ancillary

The charge amount for Toradol ($30.00) and the administration ($20.00) will be added to the 99213 ($100) for a qualifying visit line of $150.00. The total charge line is inaccurate.

FL42 FL43 FL44 FL45 FL46 FL47

Rev CD Desc HCPCS/CPT DOS Units Total Charge

0521 OV Est 3 99213 CG 7/26/2018 1 150.00$

0636 Injection Admin 96372 7/26/2018 1 20.00$

0636 Toradol J1885 7/26/2018 1 30.00$

0001 Total Charge 200.00$

Service Detail

Service detail lines can be reported as $.01 or greater. The additional services lines CAN be reported as $.01. This eliminates artificial inflation of revenue, adjustments, and AR.

Billing Example: Medical Visit plus Ancillary

The Toradol charge amount ($30.00) plus $.01, the injection administration (20.00) plus $.01 are bundled with the $100 charge on the 99213 qualifying visit line. Medicare will use the line with the qualifying visit code (99213) to determine the total charge and calculate co-insurance.



0521 OV Est 3 99213 CG 7/26/2018 1 150.00$

0636 Injection Admin 96372 7/26/2018 1 0.01$

0636 Toradol J1885 7/26/2018 1 0.01$


7/26/2018

Bundled Services: Different Dates

“The RHC can combine incident to services furnished on a different date of service on one claim as long as they are furnished in a medically appropriate period and are incident to the service being billed. Incident to services should not be reported with modifier CG.”

Billing Example: Bundled Injection/Different Dates

The charge amount for the allergy Injection ($20.00) plus $.01 will be added to the 99213 ($100) for a qualifying visit line of $120.01.



0521 OV Est 3 99213 CG 7/26/2018 1 120.01$

0636 Allergy Injection 95115 7/26/2018 1 0.01$


Multiple Encounters

“Encounters with more than one RHC or FQHC practitioner on the same day, or multiple encounters with the same RHC or FQHC practitioner on the same day, constitute a single RHC or FQHC visit, regardless of the length or complexity of the visit or whether the second visit is a scheduled or unscheduled appointment.”

(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)

Multiple Encounters are allowed when:

The patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day (2 visits), or

The patient has a medical visit and a Behavioral health visit on the same day (2 visits), or

The patient has his/her IPPE and a separate medical and/or Behavioral health visit on the same day (2 or 3 visits).

(Medicare Benefit Policy Manual. Chapter 13. Section 40.3)

Modifier 59 OR Modifier 25

Either Modifier-59 OR Modifier-25 may be used when there are two encounters on the same day.

Modifier-59 indicates that separate conditions being treated are totally unrelated.

Modifier-59 Example

7/30/2018 North American Healthcare Management Services. Established 1992.



0521 OV Est Level 4 99214 CG 7/26/2018 1 340.00$

0521 Laceration 12002 59 7/26/2018 1 200.00$


CG Modifier? Subsequent Illness or Injury

Q13. Is modifier CG reported when a subsequent medically necessary visit that qualifies as a separate payment occurs on the same day as an earlier medically-necessary visit?

A13. No.

Q14. Should modifier CG and modifier 25 or modifier 59 be reported on the same service line together to indicate a subsequent medically necessary visit that qualifies as a separate payment?

A14. No.


CG Modifier? Subsequent Illness or Injury

Q15. Modifier 25 or modifier 59 are to be reported on the primary subsequent visit, but should it also be reported with the HCPCS code(s) for the services furnished during the subsequent visit.

A15. No. Modifier 25 or 59 is reported only on the line that represents the primary reason for the subsequent visit.


Stand-Alone Encounters

Annual Wellness Visit (AWV) and Personalized Prevention Plan Services (PPPS)

Subsequent Annual Wellness Visit

Advanced Care Planning

Medicare Preventive Screenings

Billing Example: Preventive and Ancillary

An established patient is seen and a qualifying visit of 99213 for $100 is generated. A breast/pelvic exam was performed for $75.00. A venipuncture was taken for $20.00.

The charge for the pelvic exam should NOT be bundled in the 99213 line since there will be no co-insurance applied to the preventive service. The $20.00 venipuncture charge will be bundled with the 99213 charge for $100.00.



0521 OV Est 3 99213 CG 7/2/2018 1 120.01$

0521 Breast/Pelvic G0101 7/2/2018 1 75.00$

0300 Venipuncture 36415 7/2/2018 1 0.01$


Billing Example: Multiple Preventive Services/Well Woman Exam

Medicare does not pay a well-woman exams (99381-99387). Each component will be billed instead. An annual or subsequent wellness visit (G0438/G0439) is reported for the examination, plus the breast/pelvic exam (G0101), and the pap smear (Q0091).


0521 Subsq AWV G0439 CG 7/26/2018 1 175.00$

0521 Breast/Pelvic G0101 7/26/2018 1 75.00$

0521 Pap Smear Q0091 7/26/2018 1 50.00$


Each charge is listed individually. The patient is not responsible for any co-insurance or deductible for these Medicare Preventive Services.

Telehealth

Report on UB04 with Q3014. (app. $23.17)

Can accompany an E/M service or be reported alone.

‘Remote’ physician bills an E/M code with modifier.

Telehealth

RHCs and FQHCs are not authorized to serve as a distant site for telehealth consultations, which is the location of the practitioner at the time the telehealth service is furnished, and may not bill or include the cost of a visit on the cost report. This includes telehealth services that are furnished by a RHC or FQHC practitioner who is employed by or under contract with the RHC or FQHC, or a non-RHC or FQHC practitioner furnishing services through a direct or indirect contract.

Billing Example: Telehealth

A “remote provider” evaluated a Medicare patient using telehealth equipment located in the RHC. Independent and provider-based RHCs and FQHCs bill the appropriate A/B/MAC (A) using the RHC or FQHC bill type and billing number. HCPCS code Q3014 is the only non-RHC/FQHC service that is billed using the clinic/center bill type and provider number.

Remote Provider: The payment amount for the professional service provided via a telecommunications system by the physician or practitioner at the distant site is equal to the current fee schedule amount for the service provided at the facility



780 Telehealth Originating Fee Q3014 7/15/2018 1 25.00$


Telehealth – TMHP (TMHP Policy and Procedure Manual)

3.1.2: A patient site is where the client is physically located while the service is

rendered. The patient-site must be one of the following:

Established medical site: A location where clients will present to seek medical

care. There must be a patient-site presenter and sufficient technology and medical

equipment to allow for an adequate physical evaluation, as appropriate for the

client’s presenting complaint. A defined physician-client relationship is required. A

client’s private home is not considered an established medical site.

Patient-site providers that are enrolled in Texas Medicaid may only be reimbursed for the facility fee using procedure code Q3014. Procedure code Q3014 is payable to NP, CNS, PA, physicians, and outpatient hospital providers. Charges for other services that are performed at the patient site may be submitted separately.

TMHP Policy Handbook December 2016

http://www.tmhp.com/Manuals_HTML1/TMPPM/Archive/2016/Vol2_Telecommunication_Services_Handbook.28.07.html#1802840

Home Health Certification/Recertification

Home Health Certification/Recertification

Home Health Certification (G0180): This is a face-to-face visit and eligible for an RHC Encounter AIR payment. Only Billable as encounter if patient is present.

Home Health Re-Certification: This is NOT a face-to-face visit and is ineligible for an RHC Encounter AIR payment.

CCM References

1. “Proposed New Care Coordination Services and Payment for Rural Health Clinics (RHCs) and

Federally-Qualified Health Centers (FQHCs)” Centers for Medicare and Medicaid Services. Technical Assistance Call and Presentation. August 1, 2017.

2. “Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health

Centers (FQHCs)”. MLN Matters Number MM10175 Revised. Centers for Medicare and Medicaid Services. November 13, 2017.

https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2017-08-01-CCM-Call-Presentation.pdf








https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10175.pdf






RHC-FQHC References

RHC-FQHC References

Chapter 9: Medicare Claim Processing Manual RHC-FQHC

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c09.pdf

Chapter 13: Medicare Benefit Policy Manual RHC-FQHC

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf

FQHC Qualifying Visit List and PPS Codes

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf




























Annual RHC Update – What to Expect in 2018

Charles A. James, Jr.

President and CEO

North American Healthcare Management Services

314.968.0076

[email protected]

Contact Information

Charles James, Jr. President and CEO North American Healthcare Management Services 9245 Watson Industrial Park St. Louis, MO 63126 Phone: 888.968.0076 Email: [email protected] Web: http://www.northamericanhms.com

mailto:[email protected]

http://www.northamericanhms.com/

Chronic Care Management Changes (Coordination of Care)€¦ · CPT Code 99490: Only Until December...

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