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Health Care

Rural Health Reimbursement Opportunities for 2018

Care Coordination Services for Medical, Psychiatric & Behavioral Health Conditions

April 5, 2018

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To Receive CPE Credit• Participate in entire webinar

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INTRODUCTION

Marla Dumm, CPC®, CCS-P®

Managing Consultantmdumm@bkd.com

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Chronic Care Disease Overview

• Population health • Centers for Medicare & Medicaid Services (CMS) recognizes care

management as one of the critical components of primary care that contributes to better health & care for individuals, as well as reduced spending

• According to Center for Disease Control (CDC), about 1/4 adults—117 million people—have 2+ chronic diseases

• Focusing on patients with two or more chronic conditions by providing care management services can help improve their health care quality & reduce cost

Sources: CDC, “Chronic Disease Prevention and Health Promotion,” “Chronic Disease Overview”CMS, “Delivering Coordinated Care through Chronic Care Management Services,” Webinar 11/20/16

Chronic Disease Defined

• Long-lasting conditions that can be controlled but not cured

• Conditions are expected to last at least 12 months or until death of patient

• Examples of chronic conditions (not all inclusive) Alzheimer’s disease & related dementia

Asthma

Cancer

Chronic obstructive pulmonary disease

Diabetes

Heart failure

Hypertension

Schizophrenia/psychoses

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Prevalence of Chronic Conditions

Source:CMS, “Medicare Chronic Conditions Dashboard: Region Level, Comparison of Geographic Areas by Chronic Conditions, 2015”

Per Capita Medicare & Medicaid Spending

Source: CMS, “Medicare Chronic Conditions Dashboard: Region Level, Medicare Spending by Number of Chronic Conditions, 2015”

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Introduction to CCS

Review available service types

Introduce expanded care models for medical, psychiatric & behavioral health conditions

Overview of the impact on your RHC

OUR GOALS FOR TODAY

What Are Care Coordination Services?1

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What Are Care Coordination Services?

• CMS rolled out new “Care Coordination Service” (CCS) models for FY2018

• Includes current care management services & new collaborative service models that

• Make contact with the patient from acute discharge to home• Provide ongoing care of general, chronic medical conditions• Provide expanded, ongoing collaborative care of chronic

psychiatric & behavioral health conditions with additional care team members

Care Coordination Services Include

Transitional Care Management

(TCM)

Chronic Care Management

(CCM)

General Behavioral

Health Integration (BHI)

Psychiatric Collaborative Care Model

(CoCM)

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Transitional Care Management2

Home

Domiciliary Care

Rest Home

Assisted Living

Inpatient Hospital

Partial Hospital

Observation Status

Skilled or Non-skilled

Nursing Facility

Transitional Care Management Services

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Transitional Care Management (TCM)

• Patient has a medical condition or psychosocial problem that requires moderate to high decision making

• Service begins from the point of acute discharge to the home or community setting for no more than 30 days

• Health care professional accepts care of the beneficiary & provides ongoing care without a gap

• Health care professional takes responsibility for transitional care

Source: CMS, Transitional Care Management Services, ICN 908628, December 2016

TCM – Moderate Complexity• 99495 – TCM services with these

required elements• Communication (direct contact,

telephone, electronic) with the patient &/or caregiver within 2 business days of discharge

• Medical decision making/moderate

• Face-to-face (FTF) visit, within 14 calendar days of discharge

• Must occur with a RHC core provider to meet criteria for billable encounter

• Medication reconciliation/management no later than the date of the FTF visit

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TCM – High Complexity

• 99496 – TCM services with these required elements

• Communication (direct contact, telephone, electronic) with the patient &/or caregiver within 2 business days of discharge

• Medical decision making/high

• FTF visit within 7 calendar days of discharge

• Must occur with a core provider to meet criteria for a billable encounter

• Medication reconciliation/management no later than the date of the FTF visit

TCM Service Criteria

• Required “contact” must occur within 2 days of discharge• By ancillary staff or core provider

• May be with the patient or caregiver

• Direct contact, telephone or other electronic means

• Addressing patient status & needs post discharge

• On business days = Monday through Friday except holidays

• If 2 or more separate attempts are made but are unsuccessful, then the criteria for contact are met

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TCM Service Billing & Reimbursement

• TCM services must be furnished within the 30 days post discharge

• Ancillary staff work may be performed under general supervision (effective January 1, 2017)

• CPT code 99495 or 99496 is reported on the RHC UB-04 (TOB 711) with RC 521

• Reimbursement for the 7- or 14-day FTF visit with a core provider is made under the AIR

• If the FTF visit is performed on the same day as another medical service, only one AIR is paid

• Patient coinsurance & deductible applies

Chronic Care Management & Behavioral Health Integration3

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What Is Chronic Care Management (CCM)?

CMS defines CCM as:

“Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline.”

What Is Behavioral Health Integration (BHI)?

• BHI is a team-based, collaborative approach to care that focuses on integrative treatment of patients with primary care & mental or behavioral health conditions

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Who Can Provide CCM & BHI Services?

• An attending provider would be working with a collaborative care team to include

• Physicians

• Nurse Practitioners (NPs)

• Physician Assistants (PAs)

• Certified Nurse Midwives (CNMs)

Who Can Provide CCM & BHI Services?

• Auxiliary staff• Must meet applicable State law, licensure & scope of practice

requirements• Must be working under “incident to” the care plan & under the

general direction of the attending physician or non-physician practitioner

• Staff may include• Nursing staff, i.e., RN, LPN

• Medical assistant

• Pharmacist

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General Supervision Criteria

• For dates of service on or after January 1, 2017

• General (versus direct) supervision is allowed in the RHC setting for CCM services

• Allows for inclusion of ancillary staff, non-face-to-face “incident to” service time that is provided during or outside of posted RHC hours

Source: Medicare Physician Fee Schedule Final Rule, CMS-1654-F, Pages 762–764

New Coding Guidelines

• New code established for RHC/FQHC settings effective January 1, 2018

• G0511 – General care management

• For medical, psychiatric or behavioral health chronic conditions

• For a minimum of 20 minutes per calendar month

• Billed on the RHC/FQHC UB-04 to Medicare Part A

• Revenue code – 521

• Payment allowance

• Made under the Physician Fee Schedule Non-Facility Rate

• No geographic adjustment

• Average of the comparable CPT codes (99490, 99487 & 99484)

• 2018 allowance: $62.28

• Coinsurance/deductible are applicable

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Patient Eligibility – Two Options

• Option A – General Medical CCM• Patient has 2+ chronic medical conditions

• Conditions expected to last at least 12 months or until the death of the patient or place the patient at significant risk of death, acute exacerbation/decompensation or functional decline

• Option B – BHI• Patient with any behavioral health or psychiatric condition being

treated by a RHC provider that is determined to warrant BHI services

• Includes substance use disorders

Initiating Services

• The attending physician or non-physician practitioner determines if patient is eligible for services• For behavioral health, a Licensed Clinical Social Worker or Clinical Psychologist

may recommend a patient may benefit from CCM, but only the core medical provider can determine eligibility & initiate the service

• A face-to-face AWV, IPPE or other E/M visit (to establish relationship) with the physician, NP, PA or CNM is required no more than one year prior to starting services• Telehealth visits do not meet the criteria for the required FTF visit

• Discussion regarding chronic care services may have occurred at the time of the FTF visit, or within the following year

• Patient consent must be obtained before services may begin

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Obtaining Consent

• Provider cannot bill for CCM services unless he/she secures written or verbal consent from the patient

• The attending provider must document in the medical record that all elements of the beneficiary consent were provided, & that the patient accepted or declined

• A separate consent would need to be obtained for general behavioral health or psychiatric collaborative services

Obtaining Consent

• Patient must acknowledge that the attending provider explained (list not all inclusive)

• Services to be provided

• Cost sharing (patient coinsurance/deductible) & the differences if the patient receives both medical & psychiatric/behavioral health care management

• One provider will bill per calendar month (if services are necessary & criteria met)

• Patient may stop services at any time (effective at the end of a calendar month)

• Permission to consult with any relevant specialists (in or outside the RHC)

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Care Plan

• Medical CCM requires an electronic care plan, periodically reviewed & updated

• Based on physical, mental, cognitive, psychosocial, functional & environmental assessment (reassessment)

• Inventory of resources & support systems

• Care plan for all health issues with focus on the chronic conditions managed

• Patient must receive a copy of the plan

• Includes scheduling & receipt of preventive services

• Medication management & reconciliation

• NOTE: An electronic care plan is not required for general behavioral health integration as long as service criteria are met

Service Criteria

• Timely sharing of information within & outside of the primary care team/medical practice

• Certified EMR structured recording of a limited data set

• Care plan transmission by fax

• Continuity of care with a designated care team member

• 24/7 availability to care team

• Methods of communication between patient & care team, e.g., secure email, phone calls

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Certified EHR Technology

• Use of a certified EHR should facilitate

• Standardized formatting for demographics, problems, medications, allergies, etc.

• Electronic care plan

• Outside of office hours, timely access by staff for updates to the care plan or documentation in the medical record

• Housing of beneficiary consent(s)

• Housing of beneficiary receipt of care plan

• Document communication to & from home-based & community-based providers

• Patient to provider communications

• Care referrals

Source: CMS, ICD 909433 December 2016

Additional Service Criteria – BHI

• For those patients who warrant general behavioral health integration services, the following criteria are required

• Initial assessment

• Follow-up monitoring

• Behavioral health care planning, including revisions for patients who may not be progressing or whose status changes

• Facilitating & coordinating additional treatment (separately billable)• Psychotherapy

• Pharmacotherapy

• Psychiatric counseling or consultation

• Continuity of care by the designated care team member

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Billing Criteria

• Must have provided at least 20 minutes of CCM services per calendar month

• Services must be provided under the overall direction of the attending provider, i.e., MD, DO, NP, PA, CNM

• Services provided by auxiliary staff must be provided under general supervision

Non-Face-to-Face Service Documentation

• Medical record documentation must include• Date & time

• Person furnishing services

• Description of services provided• Performing medication reconciliation

• Oversight of beneficiary self-management of medication(s)

• Ensuring receipt of all recommended preventive services

• Monitor beneficiary’s condition (mental, physical & social)

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Psychiatric Collaborative Care Model (CoCM)4

Psychiatric CoCM Services & Care Team Scope

• An attending provider would be working with a collaborative care team to include

• Physicians

• Nurse Practitioners

• Physician Assistants

• The medical provider is responsible for• Directing the behavioral health care manager or clinical staff

• Overseeing the care of the patient, to include medication prescriptions, treatment for medical conditions & making referrals for specialty care as needed

• Providing ongoing oversight, management, collaboration & reassessment throughout the calendar month

Source: CMS, MLN Matters MM10175, Implementation Date: January 2, 2018

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Psychiatric CoCM Services & Care Team Scope

• Behavioral health care manager• Provides assessment & care management

• Administers validated rating scales

• Facilitates behavioral health planning associated with behavioral/psychiatric health problems diagnosed & managed

• Provide revisions to the care plan for a patient who is not progressing according to the care plan, or whose status changes

• Provide psychosocial intervention

• Collaborates with the medical team provider

• Consults with the psychiatric consultant

• Provides face-to-face services (separately billable therapy, diagnostic evaluation, medication management)

• Maintains the continuous relationship with the patient

• Maintains a collaborative relationship with the rest of the care team

Source: CMS, MLN Matters MM10175, Implementation Date: January 2, 2018

Psychiatric CoCM Services & Care Team Scope

• Psychiatric consultant

• Participates in regular reviews of the clinical status of the patient

• Advises the medical care provider

• Diagnostic information

• Options for resolving issues with lack of adherence or tolerance of the treatment

• Adjusting the treatment plan as needed

• Managing negative interactions between the psychiatric/behavioral health & medical treatment plans

• Facilitating referrals

Source: CMS, MLN Matters MM10175, Implementation Date: January 2, 2018

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New Coding Guidelines

• New code established for RHC/FQHC settings effective January 1, 2018

• G0512 – Psychiatric CoCM

• For psychiatric or behavioral health chronic conditions requiring collaborative care with a specialty care team

• For minimum of 70 minutes for the first calendar month, & a minimum of 60 minutes for any subsequent calendar months

• Billed on the RHC/FQHC UB-04 to Medicare Part A

• Revenue code – 521

• Payment allowance

• Made under the Physician Fee Schedule Non-Facility Rate

• No geographic adjustment

• Average of the comparable CPT codes (99490, 99487 & 99484)

• 2018 allowance: $145.08

• Coinsurance/deductible are applicable

Patient Eligibility

• Patient has behavioral health or psychiatric condition(s) that are currently being treated by the medical provider

• The medical provider has determined the patient would benefit from psychiatric CoCM services

• Can include substance use disorders

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Initiating Services

• The attending physician or non-physician practitioner determines if patient is eligible for services

• A face-to-face AWV, IPPE or other E/M visit (to establish relationship) with the physician, NP, PA or CNM is required no more than one year prior to starting services• Telehealth visits do not meet the criteria for the required FTF visit

• Discussion regarding chronic care services may have occurred at the time of the FTF visit, or within the following year

• Patient consent must be obtained before services may begin

Obtaining Consent

• Provider cannot bill for CCM services unless he/she secures written or verbal consent from the patient

• The attending provider must document in the medical record that all elements of the beneficiary consent were provided, & that the patient accepted or declined

• A separate consent would need to be obtained for general behavioral health or psychiatric collaborative services

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Obtaining Consent

• Patient must acknowledge that the attending provider explained (list not all inclusive)

• Services to be provided

• Cost sharing (patient coinsurance/deductible) & the differences if the patient receives both medical & psychiatric/behavioral health care management

• One provider will bill per calendar month (if services are necessary & criteria met)

• Patient may stop services at any time (effective at the end of a calendar month)

• Permission to consult with any relevant specialists (in or outside the RHC)

Billing Criteria

• Must have provided at least 70 minutes of CoCM services in the initial calendar month

• Must have provided at least 60 minutes of CoCM services in any subsequent calendar months

• Services must be provided under the overall direction of the attending medical provider, i.e., MD, DO, NP, PA, CNM, & collaboration with the behavioral health care manager & psychiatric consultant

• Services provided by auxiliary staff must be provided under general supervision

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Non-Face-to-Face Service Documentation

• Medical record documentation must include• Date & time

• Person furnishing services

• Description of services provided• Performing medication reconciliation

• Oversight of beneficiary self-management of medication(s)

• Ensuring receipt of all recommended preventive services

• Monitor beneficiary’s condition (mental, physical & social)

Additional Information

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Billing

• What date of service should be reported on the UB-04 claim?

• Either the date of service that the service requirements have been met, or any date after that, as long as it is on or before the last day of the month

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf

“Counting” Documented Time

• If more than one care team member spent time discussing a patient’s care, how is time counted?

• “If 2 or more RHC or FQHC practitioners or auxiliary staff people are discussing the patient’s care coordination, only one person’s time would be counted.

• For example, if 2 people are discussing care for 5 minutes, then 5 minutes would be counted, not 10 minutes.”

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf

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Are Services Required Every Month?

• “Q54. Once a patient has consented to receive care management services, do the services have to be provided every month?

• A54. Care management services should only be furnished on an as-needed basis. The consent for receiving care management services remains in effect until revoked, even if no CCM services are furnished.”

Source: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf

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Medicare Cost Report Reimbursement

• Chronic Care Management costs

• CMS has added a line to report costs associated with CCM costs

• Reimbursed on physician fee schedule

• Excluded from RHC cost per visit

• Separately identify & track CCM costs

Can We Provide CCS Services to Non-Medicare Patient?

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“The value of an idea lies in the using of it.”

~ THOMAS EDISON

References

• Centers for Medicare & Medicaid Services (CMS), Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), Frequently Asked Questions, February 2018

• CMS, MLN Matters MM10175

• CMS, MLN Matters MM10350

• Medicare Benefit Policy Transmittal 238

• CMS, “Proposed New Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs)”, August 1, 2017, Corinne Axelrod, Senior Health Insurance Specialist, CMS Center for Medicare, and Michelle Oswald, Program Manager, CMS Office of Minority Health

• American Medical Association (AMA), Current Procedural Terminology (CPT) 2018 Professional Edition, Pages 47–55

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Disclosure

Information contained within this session was used as a visual aid for informational purposes during a presentation led by a BKD, LLP advisor. This content was not designed to be utilized without the verbal portion of the presentation. Accordingly, information included within these slides, in some cases, are only partial lists of requirements, recommendations, etc. & should not be considered comprehensive. These materials are issued with the understanding they must not be considered legal advice.

Copyright

CPT codes copyright 2018 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use.

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Questions?

Continuing Professional Education (CPE) Credits

BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.nasbaregistry.org.

The information contained in these slides is presented by professionals for your information only & is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered.

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• CPE credit may be awarded upon verification of participant attendance

• For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at training@bkd.com

CPE Credit

Thank You!Marla Dumm | mdumm@bkd.com