rural health reimbursement … health reimbursement opportunities & ub-04 billing changes ......

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RURAL HEALTH REIMBURSEMENT OPPORTUNITIES & UB-04 BILLING CHANGES FOR 2016

Marla Dumm, CPC, CCS-PManaging Consultant

[email protected]

Steve PardeManaging [email protected]

March 9, 2016

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• Participate in entire webinar• Answer polls when they are provided• If you are viewing this webinar in a group

Complete group attendance form with• Title & date of live webinar• Your company name• Your printed name, signature & email address

All group attendance sheets must be submitted to [email protected] within 24 hours of live webinar Answer polls when they are provided

• If all eligibility requirements are met, each participant will be emailed their CPE certificates within 15 business days of live webinar

TO RECEIVE CPE CREDIT

• Overview of Chronic Care Management (CCM) Services

• Overview of Advanced Care Planning (ACP) Services

• Overview of Rural Health Clinic (RHC) UB-04 Detailed Billing Requirements

• Potential Cost Report Impact of 2016 Detailed Billing Requirements

4 // experience momentum

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CHRONIC CARE DISEASE OVERVIEWPopulation 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 2/3 of Medicare beneficiaries—117 million people—have two+ chronic diseases

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


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CHRONIC DISEASE DEFINED• Chronic disease is a long-lasting condition that can be controlled

but not cured• Condition is 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


CHRONIC CARE MANAGEMENT DEFINED

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.”


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CCM SCOPE OF SERVICE

According to CMS, providing chronic care management to beneficiaries with multiple chronic conditions requires a multidisciplinary care approach


CCM multidisciplinary care approach should involve, but not be limited to, the following• Communication with other health professionals not employed in same

rural health clinic who are involved in patient’s care• Management of care transitions between & among health care providers

& settings, including referrals to other clinicians• Follow-up after an emergency department visit or discharges from

hospitals, skilled nursing facilities or other health care facilities• Coordination with home-based & community-based clinical service

providers


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CCM SCOPE OF SERVICE REQUIREMENTS• CCM service initiation during an annual well visit (AWV), Initial Preventive

Physical Exam (IPPE) or comprehensive E/M visit that is billed separately• Provide at least 20 minutes of non-face-to-face care management services

in a calendar month• Non-face-to-face services provided by ancillary staff MUST BE PERFORMED

UNDER DIRECT SUPERVISION• Beneficiary access to care management services 24/7• Continuity of care with a designated practitioner or care team member• Monitor beneficiary’s condition—care management of chronic conditions


CCM SCOPE OF SERVICE REQUIREMENTS • Ensure beneficiary receipt of preventive care services• Medication reconciliation• Oversight of beneficiary self-management of medications• Follow-up after ER visits• Help coordinate transition of care

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WHO IS ELIGIBLE TO BILL FOR CCM?• Physicians• Certified Nurse Midwives• Clinical Nurse Specialists Are not eligible core providers in

RHC setting

• Nurse Practitioners • Physician Assistants• CMS excludes Licensed Clinical Social

Workers & Clinical Psychologistsas eligible practitioners



MEDICARE BENEFICIARY CONSENT

• Provider cannot bill for CCM services unless he/she secures a written consent from beneficiary

• Beneficiary must acknowledge provider has explained (list not all inclusive) CCM program Manner in which CCM services will be provided Health information will be shared with other practitioners Only one practitioner can provide these services during a

calendar month Beneficiary has right to stop CCM services at any time

• Patient consent form(s) should include how to revoke service

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NON-FACE-TO-FACE SERVICE DOCUMENTATION• Documentation must include Date & time Person furnishing services Description of services

• Performing medication reconciliation, oversight of beneficiary self-management of medications

• Ensuring receipt of all recommended preventive services• Monitor beneficiary’s condition (mental, physical & social)


COMPREHENSIVE CARE PLAN• Create a patient-centered care plan based on physical, mental

cognitive, psychosocial, functional & environmental (re)assessment & inventory of resources (a comprehensive plan of care for all health issues)

• Provide patient with a written or electronic copy of care plan & document its provision in medical record

• Ensure care plan is available electronically at all times to anyone within practice providing CCM service

• Share care plan electronically outside practice as appropriate

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CCM CERTIFIED TECHNOLOGY• Requires use of certified EHR technology to satisfy many CCM scope

of service elements• Technology used to furnish CCM services beginning on January 1,

2016, would be required to meet, at a minimum, requirements included in 2014 certification criteria edition(s) http://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms

CCM TECHNOLOGY REQUIREMENTS• Provider must be able to transmit summary record for purposes of

care coordination• House beneficiary consent of CCM services• House beneficiary receipt of care plan Must have ability to provide a copy to beneficiary

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

• Plan must be accessible 24/7 to all care team members & other providers caring for beneficiary


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CCM BILLING & CPT CODE REQUIREMENTS

Chronic Care Management (CPT 99490)According to the CMS Chronic Care Management Fact Sheet, CPT 99490 is defined as


CCM BILLING & CPT CODE REQUIREMENTS

• Codes/services that cannot be reported during same month as CCM Transitional care management (CPT codes 99495 - 99496)

• TCM & CCM services may be provided in same calendar month if furnished service periods do not overlap

Home health & hospice care supervision (HCPCS codes G0181 - G0182) End-stage renal disease service (CPT codes 90951 - 90970) Overlap with CMS demonstration or other initiatives that pay for similar

services


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2016 CMS PAYMENT• Payment for CCM services will be “based on the Medicare PFS

national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services”

• Rate will be updated annually• No geographic adjustment• Coinsurance & deductible apply• 2016 payment rate = $40.82

CONCLUSIONNew rule from CMS allowing reimbursement for CCM services is a huge change that will allow physicians to• Improve patient care for Medicare

beneficiaries dealing with chronic diseases

• Now get paid for work they are already doing to care for chronically ill patients

• Potentially increase revenue for their rural health clinic providers


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• Making advanced plans for patient-desired care when facing a serious illness

• Discussions between patients & providers about Future care decisions that may need to be

made How beneficiary can let others know about

care preferences Explanation of advance directives & other

legal documents May also involve completion of standard

forms

WHAT IS ADVANCED CARE PLANNING (ACP)?

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• Care decisions may include, but not be limited to Choosing or refusing diagnostic testing, invasive procedures &/or

medication Whether to perform or continue life-sustaining treatment Stating who is allowed to make care decisions when patient cannot

ADVANCED CARE PLANNING

• Effective January 1, 2016, ACP will be a stand-alone billable visit in RHC setting CPT code 99497

• Performed by an RHC physician or qualified health professional Physician Nurse Practitioner Physician Assistant LCSW Licensed Clinical Psychologist

ADVANCED CARE PLANNING – COVERAGE & BILLING

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• ACP services may be furnished on same day as another billable medical visit Only one AIR will be paid Coinsurance & deductible will apply

• ACP services may be furnished on the same day as an Annual Wellness Visit (AWV) Only one AIR will be paid Coinsurance & deductible will be waived

ADVANCED CARE PLANNING – COVERAGE & BILLING

ADVANCED CARE PLANNING – BILLING EXAMPLE

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ADVANCED CARE PLANNING – BILLING EXAMPLE


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• Prior to 2016, RHCs were not required to report CPT/HCPCS codes other than for covered preventive services (i.e., G0101)

• NEW Effective April 1, 2016, all RHCs, to include those exempt from electronic reporting, will be required to report CPT/HCPCS codes on UB-04 for each service furnished during encounter

• Appropriate revenue code(s) will be reported for each line item• Payment will continue to be made under all-inclusive rate (AIR)

2016 RHC DETAILED BILLING REQUIREMENTS

• NEW An RHC “qualifying visit” is defined by CMS as A medically necessary medical visit (E/M) A medically necessary mental health visit A qualified face-to-face preventive health visit

• Examples IPPE AWV G0101 well woman breast/pelvic examination

Transitional care management (TCM) services & Advanced Care Planning (ACP) now allowed as stand-alone visits

Face-to-face, with a core provider, during which RHC services are furnished• Includes services furnished “incident to” core provider during visit

DETAILED BILLING – QUALIFYING VISIT

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• NEW CMS has provided a list of “qualifying visit” codes that will prompt AIR payment See MLN Matters MM9269, pages 8 - 10 Includes primarily E/M services, mental health services & covered

preventive services (i.e., G codes)

• NEW CPT procedure codes (i.e., joint injection, lesion removal) are NOT listed as qualifying visits. Therefore, a “procedure only” encounter will not meet criteria as a billable encounter

DETAILED BILLING – QUALIFYING VISIT

• Medicare Benefit Policy Manual, Chapter 13, §40.4, Rev. 220, Effective February 1, 2016• “Surgical procedures furnished in a RHC or FQHC by a RHC or FQHC practitioner

are considered RHC or FQHC services. Procedures are included in the payment of an otherwise qualified visit and are not separately billable. If a procedure is associated with a qualified visit, the charges for the procedure go on the claim with the visit. Payment is included in the AIR with the procedure is furnished in a RHC, and payment is included in the PPS methodology when furnished in a FQHC.”

• NARHC has relayed concern & provider comments to CMS, & this issue is under consideration. CMS should provide a response prior to April 1, 2016, implementation date

DETAILED BILLING – QUALIFYING VISITS (NEW)

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• NEW Line item on UB-04 that has a “qualifying visit” CPT/HCPCS code will prompt AIR payment

• Professional component of qualifying medical service or preventive health service Revenue code 052X

• Qualifying mental health service Revenue code 0900

• Telehealth originating site facility fee Revenue code 0780

DETAILED BILLING – SERVICE LINE

• Every RHC service furnished during a billable encounter will be listed on a separate line item on UB-04 with CPT/HCPCS code

• “Qualifying visit service lines” will be tied to a 052x, 0900 or 0780 revenue code

• NEW Additional medical services or incident to services will be reported on separate lines with revenue codes & CPT/HCPCS codes All valid UB-04 revenue codes may be reported EXCEPT FOR 002x-024x, 029x,

045x, 054x, 060x, 067x-072x, 080x-088x, 093x or 096x-310x• REMINDER: Sole performance of “incident to” services does not meet criteria for a

billable encounter

DETAILED BILLING – ADDITIONAL SERVICES & REVENUE CODES

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• When multiple services are furnished during encounter, 052x or 0900 revenue code line (i.e., service line) will include total charges for all services on claim

• EXCEPTION Charge for a covered preventive service (i.e., IPPE, AWV, well woman

exam) is listed separately with CPT/HCPCS code & 052x revenue code. Charge is not rolled into total, but is deducted from total charge for purposes of calculating beneficiary coinsurance accurately

DETAILED BILLING – “ROLLING” CHARGES

DETAILED BILLING – EXAMPLE

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• Single medical service A single line item will be listed on UB-04, with appropriate 052x

revenue code & charge. Payment is made under AIR

DETAILED BILLING EXAMPLE – MEDICAL

• Preventive annual well woman exam (i.e., G0101) furnished with a medical visit (i.e., 99213 established visit) will not prompt an additional AIR payment, except for IPPE

DETAILED BILLING EXAMPLE – MEDICAL + PREVENTIVE

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• Furnishing a covered preventive service (i.e., annual well women/breast & pelvic examination G0101) as only “qualifying visit” will prompt appropriate AIR payment. Calculation of coinsurance/deductible is waived if applicable

DETAILED BILLING EXAMPLE – PREVENTIVE SERVICE

• Furnishing psychotherapy with patient & family (90834) will prompt an AIR payment. The charge from the additional medication management service (90863) will be listed separately and the charge “rolled” to the “qualifying service” line.

DETAILED BILLING EXAMPLE – MENTAL HEALTH SERVICE

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• RHCs will report a separate line item for each service performed during medical encounter. Example: an established patient visit (i.e., 99213) with performance of a simple laceration repair (i.e., 12002). 99213 service line (revenue code 521) will prompt AIR payment

DETAILED BILLING EXAMPLE – MULTIPLE MEDICAL SERVICES

• Services & supplies furnished “incident to” core provider’s encounter are included in AIR & not separately paid. “Service line” will include total charges for encounter. An example is an established visit with ordered lab draw and Hep B vaccination.

DETAILED BILLING EXAMPLE – MEDICAL + INCIDENT TO

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• Multiple visits by same patient with more than one RHC core provider, or with same core provider, result in a single AIR payment

• EXCEPTIONS If patient is seen for qualifying medical & qualifying mental health visit on

same date If patient suffers an illness or injury subsequent to their initial visit &

requires additional diagnosis or treatment on same day If patient has a medical or mental health visit AND an IPPE on same date of

service. Coinsurance/deductible are waived for IPPE service

DETAILED BILLING EXAMPLE – MULTIPLE VISITS/SAME DAY

• Modifier -59 should be appended to service line CPT/HCPCS code(s) for additional qualifying visit(s)

DETAILED BILLING EXAMPLE – MULTIPLE VISITS/SAME DAY

Revenue Code

HCPCS Service Date

Service Units

Total Charges

Payment Coinsurance/ Deductible Applied

052X 99213 4/3/16 1 $XX.XX AIR YES

900 90834 -59 4/3/16 1 $XX.XX AIR YES

052X G0402-59 4/3/16 1 $XX.XX AIR NO

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• Review current CMS transmittals & instruction for new CCM & ACP services

• Keep current on CMS instruction for detailed billing through list serves and newsletters

• Provide internal professional staff training• Add codes to clinic fee schedule• Monitor provider documentation & compliance with

service criteria• Review guidelines for detailed billing• Work with vendors to implement new billing

requirements• Monitor claims & remittance advices for appropriate

reporting & associated payment• Perform internal testing of detailed billing UB-04

claims prior to April 1

FINAL THOUGHTS

REFERENCES Centers for Medicare & Medicaid Services (CMS), MLN Matters, MM9269

Revised CMS, MLN Matters, SE1516 CMS, Pub 100-20 One-Time Notification, Transmittal 1576 CMS, MLN Matters, MM9234, Transmittal R1576OTN CMS, 42 CFR Parts 405, 410, 411, 414, 425 & 495, “Medicare Program:

Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016,” Final Rule

CMS, MLN Matters, MM9269 Revised 2/29/16 National Government Services, Medicare University, “Billing Guidelines for

Federally Qualified Healthcare Centers,” May 2014

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REFERENCES National Association of Rural Health Clinics (NARHC), “Chronic Care

Management (CCM) in Rural Health Clinics”, Rural Health Clinic Technical Assistance Webinar, Captain Corinne Axelrod, MPH, L.Ac., Dipl.Ac., CMS, Centers for Medicare, Hospital and Ambulatory Policy Group, January 19, 2016

NARHC, “Advanced Care Planning (ACP) in Rural Health Clinics,” Rural Health Clinic Technical Assistance Webinar, Simone Dennis, MSPH, CMS, Center for Medicare, Hospital and Ambulatory Policy Group, January 10, 2016

NARHC, “Chronic Care Management for RHCs Begins”


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• Maximum RHC payment per visit for calendar 2016 is $81.32 for non-exempt & freestanding RHCs

• Hospital-based RHCs with less than 50 beds are not subject to RHC payment per visit limitation Critical Access Hospitals

• Hospital-based RHCs with less than 50 beds Allowable cost per visit is determined by dividing greater of actual total visits or

visits as computed using productivity limits• Payment per visit or cost reimbursement per visit remains the same

regardless of complexity of service

MEDICARE COST REPORT REIMBURSEMENT

• Total Medicare RHC allowable costs RHC health care staff costs

• Wages for physicians & mid-levels need to be adjusted for amount related to professional services – those related to non-RHC services

Costs under agreement Other health care costs Hospital overhead costs Excludes nonallowable costs & non-RHC costs


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• RHC services In-office visits In-office surgical services Nursing home visits – including skilled swing bed in hospital Home visits

• Non-RHC services Emergency 4oom time spent Inpatient rounds Hospital administrative duties X-Ray services Laboratory services


• Productivity limits Number of visits used to determine cost per visit may be impacted by

productivity limits• Applicable to mid-level practitioners & employed & regularly contracted

physicians 4,200 visits per physician FTE 2,100 visits per mid-level FTE

• Calculation is combined, not line-item specific


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• FTE calculation Calculated by dividing productive hours by 2,080 Productive hours is defined as total paid hours minus

• Vacation• Sick leave• CME• Non-RHC services• Administrative duties


Example 1


Number of FTE

PersonnelTotal Visits

Productivity Standard (1)

Minimum Visits (col. 1 x

col. 3)

Greater of col. 2 or col. 4

1.00 2.00 3.00 4.00 5.00VISITS AND PRODUCTIVITYPositions

1.00 Physician 0.83 2,000 4,200 3,486 2.00 Physician Assistant - - 2,100 - 3.00 Nurse Practitioner 1.00 3,800 2,100 2,100 8.00 Total FTEs and Visits (sum of lines 4 through 7) 0.93 5,800 5,586 9.00 Physician Services Under Agreements - -

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Example 1


1.00DETERMINATION OF RATE FOR RHC/FQHC SERVICES

1.00 Total Allowable Cost of RHC/FQHC Services (from Wkst. M-2, line 20) 1,068,000 2.00 Cost of vaccines and their administration (from Wkst. M-4, line 15) 24,000 3.00 Total allowable cost excluding vaccine (line 1 minus line 2) 1,044,000 4.00 Total Visits (from Wkst. M-2, column 5, line 8) 5,800 5.00 Physicians visits under agreement (from Wkst. M-2, column 5, line 9) - 6.00 Total adjusted visits (line 4 plus line 5) 5,800 7.00 Adjusted cost per visit (line 3 divided by line 6) 180.00

Example 1


Prior to January 1

On on After January 1

8.00 Per visit payment limit (from CMS Pub. 100-04, chapter 9, §20.6 or your contractor) 80.44 81.32 9.00 Rate for Program covered visits (see instructions) 180.00 180.00

CALCULATION OF SETTLEMENT10.00 Program covered visits excluding mental health services (from contractor records) - 2,030 11.00 Program cost excluding costs for mental health services (line 9 x line 10) - 365,400

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• Case Study – Now Patient goes to RHC for knee pain Physician performs evaluation & management with injection Physician requests follow-up injection in two weeks Initial evaluation & management & injection by physician is billed as a

qualifying RHC visit Subsequent injection by physician is billed as a qualifying RHC visit


• Case Study – Effective April 1, 2016 Patient goes to RHC for knee pain Physician performs an evaluation & management with an injection Physician requests follow-up injection in two weeks Initial evaluation & management & injection by physician is billed as a

qualifying RHC visit Subsequent injection by physician cannot be billed as a qualifying RHC visit


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Example 2 – 10% reduction in qualifying RHC visits


Number of FTE

PersonnelTotal Visits

Productivity Standard (1)

Minimum Visits (col. 1 x

col. 3)

Greater of col. 2 or col. 4

1.00 2.00 3.00 4.00 5.00VISITS AND PRODUCTIVITYPositions

1.00 Physician 0.83 1,800 4,200 3,486 2.00 Physician Assistant - - 2,100 - 3.00 Nurse Practitioner 1.00 3,420 2,100 2,100 8.00 Total FTEs and Visits (sum of lines 4 through 7) 0.93 5,220 5,586 9.00 Physician Services Under Agreements - -

Example 2 – 10% reduction in qualifying RHC visits


1.00 1.00DETERMINATION OF RATE FOR RHC/FQHC SERVICES

1.00 Total Allowable Cost of RHC/FQHC Services (from Wkst. M-2, line 20) 1,068,000 1,068,000 2.00 Cost of vaccines and their administration (from Wkst. M-4, line 15) 24,000 24,000 3.00 Total allowable cost excluding vaccine (line 1 minus line 2) 1,044,000 1,044,000 4.00 Total Visits (from Wkst. M-2, column 5, line 8) 5,220 5,586 5.00 Physicians visits under agreement (from Wkst. M-2, column 5, line 9) - - 6.00 Total adjusted visits (line 4 plus line 5) 5,220 5,586 7.00 Adjusted cost per visit (line 3 divided by line 6) 200.00 186.90

Decrease in the adjusted cost per visit (13.10) Medicare visits 1,955 Medicare reimbursement impact (25,620)

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• Strategies Absolutely critical to develop & maintain accurate RHC physician & mid-

level RHC time studies to determine• Productive time in RHC

Consider electing to file consolidated RHC worksheets in advance of cost reporting period


• Strategies – RHC physician & mid-level time studies Purpose is to determine allowable RHC productive time & costs Review contract – what does he/she get paid for? Determine RHC physicians & mid-level roles, responsibilities & duties Track physician & mid-level RHC productive time, professional time & other


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• During RHC hours of operation RHC face time with patient Time available in RHC not seeing patients RHC qualifying swing bed visits RHC qualifying nursing home visits RHC dictation & charts Medical staff meetings Board meetings


• During RHC hours of operation Emergency room time Emergency room dictation & chart review Inpatient round time Inpatient round dictation & chart review Surgery assistance EKGs Providing community education


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• During RHC hours of operation Primary call pay – nonallowable Back-up call pay – nonallowable

• Outside RHC hours of operation Medical staff meetings Board meetings Emergency room time Emergency room dictation & chart review


• Outside RHC hours of operation Inpatient round time Inpatient round dictation & chart review Primary call pay Back-up call pay

• Other Continuing medical education Vacation time Sick leave


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• Chronic Care Management Costs CMS will be adding 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


QUESTIONS?

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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.learningmarket.org.

The information in BKD webinars is presented by BKD professionals, but applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any matters covered in these webinars.


The following information was used as a visual aid during a presentation/training session led by a BKD, LLP advisor. This content was not designed to be utilized

without the verbal portion of the presentation. Accordingly, information included on these slides, in some cases, are only partial lists of requirements, recommendations,

etc. & should not be considered comprehensive. These materials are being issued with the understanding they must not be considered legal advice.

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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 [email protected]

CPE CREDIT

THANK YOU!FOR MORE INFORMATION

Steve Parde | 816.221.6300 | [email protected]

Marla Dumm | 417.865.0682 | [email protected]

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rural health reimbursement … health reimbursement opportunities & ub-04 billing changes ......

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