WHY SHOULD A CHC/FQHC CARE?

• Medicare Part A & Part B• MACRA / MIPS• Chronic Care Management Billing

Suzanne Niemi, CPA, CMPE, CCEAlaska Primary Care AssociationApril 2017

DEFINITIONS

• FQHC – Federally Qualified Health Center• Safety Net Provider that offers services typically furnished in an

outpatient setting:• Community Health Centers• CHC Look-Alikes• Outpatient programs operated by a tribe, tribal organization or

Urban Indian organization

• Organizations must apply for this status

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DEFINITIONS

• FQHC Medicare Reimbursement• Reimbursement under Medicare Part A through the

Prospective Payment System (PPS)• Paid at a per-encounter rate vs. being paid on the Fee-for-

Service model based on procedure codes

• FQHC-eligible providers must apply to Medicare Part A

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DEFINITIONS• MACRA = Medicare Access and CHIP Reauthorization Act of

2015• Pay-for-performance program that’s focused on quality,

value, and accountability• MACRA replaced three Medicare reporting programs with

MIPS• Medicare Meaningful Use (MU)• Physician Quality Reporting System (PQRS)• Value-Based Payment Modifier

• MIPS = Merit-Based Incentive Payment System• A performance-based payment system for Medicare Part B

clinicians which requires submission of performance data to CMS

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DEFINITIONS

• CCM = Chronic Care Management Billing• Reimbursement from Medicare for certain services provided

to patients with multiple (two or more) chronic conditions

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MACRA and MIPS

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DOES MACRA /MIPS APPLY TO CHCS?

• Federally Qualified Health Centers (FQHCs) are exempt from MIPS reporting

• Aren’t all CHCs considered FQHCs?• NO !!

• FQHC is a term related to billing / reimbursement methodology• CHCs must apply to Medicare Part A to be recognized and

reimbursed as an FQHC

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MEDICARE PART A vs. MEDICARE PART B

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PATIENT ENROLLMENT / COVERAGE FOR SERVICES IN A CHC

CHC Sends FQHC Claims to Medicare Part A

• Patient must be enrolled in Medicare Part B

CHC Sends Fee-for-Service Claims to Medicare Part B

• Patient must be enrolled in Medicare Part B

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Patient enrollment in Part A covers Hospital, Skilled Nursing, Nursing Home, Hospice and Home Health services

Patient enrollment in Part B covers Outpatient services, Ambulance, Durable Medical Equipment, Mental Health

Patients must be enrolled in Part B for Medicare to cover services provided by an outpatient clinic, regardless of how the provider submits claims

PROVIDER ENROLLMENT

Medicare Part A• Enroll as an organization using Form

CMS-855A• Requires organization level

information • Includes names and information of

governing board members and Executive Director (managing employee)

Medicare Part B• Enroll the group using CMS-Form

855B• Enroll individual providers using CMS

Form 855I

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BENEFITS OF ENROLLMENT

Medicare Part A• Medicare FQHC per-encounter

reimbursement rates• For non-tribal organizations:

Determines eligibility to receive state Medicaid FQHC per-encounter reimbursement rates

• Do not need to individually enroll providers in Medicare Part A

Medicare Part B• Ability to bill Medicare for services to

beneficiaries• Ability to bill for services not

reimbursable under Part A • (see additional slide for details on

what services cannot be billed to Part A)

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WHY NOT ENROLL?

Medicare Part A• Some tribal providers have decided

that the reimbursement benefit does not outweigh the reporting burden

Medicare Part B• No services are provided to

Medicare beneficiaries• No services are provided that are

outside of the Medicare Part A scope

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SPECIAL REPORTING REQUIREMENTS

Medicare Part A• Must submit a quarterly Credit

Balance Report to CMS on Form CMS-838

• Must submit a Medicare Cost report annually 5 months after year end. (much simpler than a hospital cost report)

• Alaska Medicaid requires non-tribal entities to submit a copy of the Medicare Cost Report to Medicaid

Medicare Part B• None• Periodic re-validation required

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WHAT SERVICES CAN BE BILLED?

Medicare Part A• Services provided to Medicare

beneficiaries furnished by a • Physician• Nurse practitioner (NP) • Physician assistant (PA) • Certified nurse midwife (CNM)• Clinical psychologist (CP)• Clinical social worker (CSW), or • Certified diabetes self-management

training/medical nutrition therapy (DSMT/MNT) provider

Medicare Part B• Most services provided to Medicare

beneficiaries• See next page for exclusions

• Part A providers can bill certain services to Part B (those that cannot be reimbursed under Part A)

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WHAT SERVICES ARE EXCLUDED?

Medicare Part A exclusionsServices that can be billed to Part B:• Services provided by practitioners other than

those in the previous slide• Laboratory services• Technical components of diagnostic services• Durable Medical Equipment / Prosthetic

devices / body braces• https://med.noridianmedicare.com/web/jea/

provider-types/fqhc/fqhc-billing-guide

Medicare Part B exclusionsSome of the items and services that Medicare doesn't cover at all include:• Long-term care (also called custodial care)• Most dental care• Eye examinations related to prescribing glasses• Dentures• Cosmetic surgery • Acupuncture • Hearing aids and exams for fitting them• Routine foot care

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HOW ARE CLAIMS FILED?

Medicare Part A• Submitted to Part A using UB-04

• Health Centers are required to use special CPT codes when submitting Medicare claims in addition to regular CPT codes.

• G0466, G0467, G0468, G0469 and G0470

Medicare Part B• Submitted to Part B using CMS-1500

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HOW IS THE REIMBURSEMENT AMOUNT DETERMINED?

Medicare Part A• Prior to 2014, the Medicare FQHC per-encounter

was cost-based, but was subject to a cap of about $112

• Beginning with fiscal years starting Oct 1, 2014 Health Centers are paid on a Prospective Payment System (PPS)

The rates for 2017:• $163.49 National Base Rate• 1.318 AK geographic adjustment factor (GAF)• $215.48 ESTABLISHED PATIENT VISIT• 1.3416 High Intensity Visit Adjustment• $289.09 NEW PATIENT, INITIAL PREV PHYSICAL

EXAM (IPPE) OR ANNUAL WELLNESS VISIT (AWV)

Medicare Part B• Per the Physician Fee Schedule

updated annually by CMS • The same payment rates as a

private practice provider

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HOW DOES ENROLLMENT AFFECT THE PATIENT?

Medicare Part A• There is no Part B deductible for FQHC-covered

services

• Coinsurance is 20 percent of the lesser of the FQHC’s charge for the specific payment code or the PPS rate, except for certain preventive services

• Patient cost-sharing requirements for most Medicare covered preventive services are waived, and Medicare pays 100 percent of the costs for these services

• No coinsurance is required for the IPPE, AWV, and any covered preventive services recommended with a grade of A or B by the United States Preventive Services Task Force.

Medicare Part B• Usual Deductibles and 20% Co-Payments

• Same as if they saw a private provider

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More information on Medicare Part A / FQHC co-insuranceFor a complete list of preventive services and their coinsurance requirements, refer to the Federally Qualified Health Center (FQHC) Preventive Services Chart. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-Preventive-Services.pdf

ARE CHRONIC CARE MGMT SERVICES PAID?

Medicare Part A• Yes• Code 99490 Only

• Cannot bill for new complex CCM codes

• Payment is based on the Medicare PFS national non-facility payment rate.

• The rate is updated annually and has no geographic adjustment

Medicare Part B• Yes• Can bill all CCM codes

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DOES MACRA / MIPS APPLY?

Medicare Part A• FQHC Medicare Part A providers

are exempt from mandatory MIPS reporting

• Organizations may choose to report

Medicare Part B• MIPS reporting periods begin in 2017

• There are penalties for not reporting

• Payment adjustments (+ or – ) are scheduled to be implemented in 2019 based on 2017 data

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ARE ALL ALASKA CHCS ENROLLED IN PART A?

Non-Tribal CHCs• Yes. All Alaska Non-Tribal CHCs

have applied for Part A recognition

• Non-Tribal CHCs must receive designation as a Medicare FQHC in order to qualify for state Medicaid FQHC reimbursement

Tribal CHCs• Maybe…

• Tribal Organizations enroll in Medicaid as a tribal entity

• Medicare FQHC enrollment is not required as a condition of enhanced Medicaid reimbursement

• Each Organization makes an individual decision whether or not to enroll in Part A

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MACRA and MIPSMedicare Access and CHIP Reauthorization Act of 2015

Merit-Based Incentive Payment System

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MIPS REPORTING REQUIREMENT• “The Quality Payment Program improves Medicare by helping you

focus on care quality and the one thing that matters most — making patients healthier.”

• Federally Qualified Health Centers (FQHCs) are exempt from MIPS reporting

• But, providers may choose to report

• There are over 270 measures to choose from – 55 specifically for General Practice / Family Medicine

• https://qpp.cms.gov/measures/quality

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MEDICARE PART A

PAYMENT CHANGES BASED ON

MIPS REPORTING

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• NO CHANGE TO FQHC PER-ENCOUNTER PAYMENT RATES

• For FQHCs, it is important to note that MACRA/QPP implementation will not impact your Medicare FQHC PPS payments

• Because health centers are paid their unique Medicare PPS and are not paid on the Physician Fee Schedule (“Part B”) they will not be subject to MIPS and their payment methodology will not change.

• Health Centers will be able to voluntarily report under the new MIPS, without incentive or penalty.

WHAT ABOUT FQHCs

THAT SUBMIT SOME

CLAIMSTO

PART B?

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While Part A payments will not be affected, reimbursement for any Part B claims may be affected

• Services that are billed outside of the FQHC benefit and billed to Medicare Part B separately are subject to MIPS.

• Check the low volume thresholds (see slide #27)

MEDICARE PART B

PAYMENT CHANGES BASED ON

MIPS REPORTING

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MIPS ELIGIBILITYProviders are eligible to participate in the MIPS track of the Quality Payment Program if:• You bill more than $30,000 to Medicare, and • You provide care to more than 100 Medicare patients per year, and • You are a:

• Physician• Physician Assistant• Nurse Practitioner• Clinical Nurse Specialist• Certified Registered Nurse Anesthetist

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MIPS REPORTING –PARTICIPATE AS AN INDIVIDUAL OR A GROUP?

Individual• One NPI tied to one Tax ID

Group• A group is defined as a set of clinicians (identified by their NPIs) sharing a

common Tax Identification Number, no matter the specialty or practice site.• To submit data through the CMS web interface, you must register as a group

by June 30, 2017.

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MIPS REPORTING TIMELINE• If you’re ready, you can begin January 1, 2017 and start collecting your

performance data• If you’re not ready on January 1, you can choose to start anytime between

January 1 and October 2, 2017• Whenever you choose to start, you’ll need to send in your

performance data by March 31, 2018• The first payment adjustments based on performance

go into effect on January 1, 2019

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MIPS REPORTING – CATEGORY #1

Quality (replaces PQRS)• Most participants:

• Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days

• Groups using the web interface: • Report 15 quality measures for a full year

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MIPS REPORTING - CATEGORY #2Improvement Activities• Participants in certified patient-centered medical homes, comparable

specialty practices, or an APM designated as a Medical Home Model: • You will automatically earn full credit

• Most participants: • Attest that you completed up to 4 improvement activities for a minimum

of 90 days

• Groups with fewer than 15 participants or if you are in a rural or health professional shortage area:

• Attest that you completed up to 2 activities for a minimum of 90 days

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MIPS REPORTING – CATEGORY #3

Advancing Care Information (replaces Meaningful Use)• Fulfill the required measures for a minimum of 90 days:

• Security Risk Analysis• e-Prescribing• Provide Patient Access• Send Summary of Care• Request/Accept Summary of Care

• Choose to submit up to 9 measures for a minimum of 90 days for additional credit

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MIPS REPORTING – CATEGORY #4

Cost• No data submission required

• Calculated from adjudicated claims

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HOW TO SUBMIT DATA

Individual Providers• Send individual data for each of

the MIPS categories through an electronic health record or a registry.

• You can also send in quality data through your routine Medicare claims process.

• https://qpp.cms.gov/learn/getprepared

Groups (registration open from April 1 – June 30, 2017)

Options may vary based on performance category• CMS Web Interface (only available to groups

with 25 or more eligible clinicians)• Qualified Clinical Data Registry (QCDR)• Qualified Registry• Electronic Health Record (EHR)• Administrative Claims• CAHPS for MIPS Survey (only available to

groups with 2 or more eligible clinicians)• Attestation• https://qpp.cms.gov/learn/about-group-

registration

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MIPS RESOURCES

• https://qpp.cms.gov/

• https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html

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CHRONIC CARE MANAGEMENT(CCM)

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CHRONIC CARE MANAGEMENTDefinition:• Services by a physician or non-physician practitioner (PA, NP, Clinical Nurse

Specialist, Certified Nurse-Midwife, and their clinical staff, • At least 20 minutes per calendar month,

• for patients with multiple (two or more) chronic conditions • expected to last at least 12 months or until the death of the

patient, • and that place the patient at significant risk of death, acute

exacerbation/ decompensation, or functional decline. • Comprehensive care plan established, implemented, revised, or monitored• Note that only 1 practitioner can bill CCM per service period (month)

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EXAMPLES OF CHRONIC CONDITIONS INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING:

• Alzheimer’s disease and related dementia

• Arthritis (osteoarthritis and rheumatoid)• Asthma • Atrial fibrillation• Autism spectrum disorders • Cancer• Cardiovascular Disease• Chronic Obstructive Pulmonary Disease

• Depression • Diabetes• Hyperlipidemia• Hypertension • Infectious diseases such as HIV/AIDS• Ischemic Heart Disease• Kidney Disease (Chronic)• Osteoporosis• Stroke

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CHRONIC CARE MANAGEMENT SERVICESThe CCM service is extensive, including

• Structured recording of patient health information in a certified EHR• Maintaining a comprehensive electronic Care Plan• Access to Care & Care Continuity• Comprehensive Care Management• Transitional Care Management• Coordinating and sharing patient health information timely within and

outside the practice.

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COMPREHENSIVE CARE PLANA comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:• Problem list• Expected outcome and prognosis• Measurable treatment goals• Symptom management• Planned interventions and identification of the individuals responsible for each

intervention• Medication management• Community/social services ordered• A description of how services of agencies and specialists outside the practice will be

directed/coordinated• Schedule for periodic review and, when applicable, revision of the care plan

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2017 FQHC BILLING REQUIREMENTSInitiating Visit:• For new patients or patients not seen within one year prior to the

commencement of CCM,• Medicare requires initiation of CCM services during a face-to-face visit with the

billing practitioner:• An Annual Wellness Visit (AWV), or • Initial Preventive Physical Exam (IPPE), or • Other face-to-face visit with the billing practitioner

• This initiating visit is not part of the CCM service and is separately billed

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2017 FQHC BILLING REQUIREMENTSThe FQHC must inform eligible patients of the availability of CCM services and obtain consent for the CCM service before furnishing or billing the service. • Patient consent requirements include:

• Informing the patient of the availability of the CCM service• Obtaining written agreement to have the services provided, including

authorization for the electronic communication of medical information with other treating practitioners and providers

• Explaining and offering the CCM service to the patient and documenting this discussion in the patient’s medical record, noting the patient’s decision to accept or decline the service.

• Informing the patient of the right to stop CCM services at any time (effective at the end of the calendar month)

• Informing the patient that only one practitioner can furnish and be paid for the service during a calendar month

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CCM BILLINGIn November 2016, CMS announced rule changesEnables reimbursement for more complex and more time-intensive chronic care coordination effective January 2017.

HOWEVER, these new codes are not available to FQHCs

• Only CPT 99490 is payable in FQHC and RHC settings.

• Complex CCM is not payable and there is no add-on code/separate payment for initiating visits

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CCM BILLING CODE FOR FQHCsCPT code 99490• Allows eligible practitioners and suppliers to

bill for • at least 20 minutes of non-face-to-face

clinical staff time • directed by a physician or other qualified

health professionals • each month • to coordinate care for beneficiaries who

have two or more serious chronic conditions that are expected to last at least 12 months.

THIS IS THE ONLY CODETHAT CAN BE BILLED BY Federally Qualified Health Centers (FQHCs)

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CCM ADDITIONAL BILLING CODES (not available to FQHCs)

HCPCS code G0506 • An add-on code to the CCM initiating visit for

providing a comprehensive assessment and care planning to patients.

CPT code 99487• Complex CCM that requires substantial revision of

a care plan, moderate or high complexity medical decision making, and 60 minutes of clinical staff time.

CPT code 99489• complex CCM add-on code for each additional

30 minutes of clinical staff time.

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2017 REIMBURSEMENT RATES

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2017 FQHC BILLING DETAILS

• CCM services can be billed alone or on the same claim as an office visit

• Must be billed on or before the last day of the month• Must include at least 2 chronic condition diagnosis codes• Billed each month that services have been documented. • Does not need to be consecutive months• No revenue code restrictions• Note that time spent must be documented

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2017 CCM BILLING SUMMARY• FQHCs can bill for CCM services when a FQHC practitioner furnishes a

comprehensive evaluation and management (E/M) visit, Annual Wellness Visit (AWV), or Initial Preventive Physical Examination (IPPE) to the patient prior to billing the CCM service, and initiates the CCM service as part of this visit.

• CCM payment will be based on the Medicare Physician Fee Schedule national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services on a FQHC claim.

• The rate will be updated annually and has no geographic adjustment. • The FQHC face-to-face requirements are waived when CCM services are

furnished to a FQHC patient.

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2017 CCM BILLING SUMMARY (cont’d)• Coinsurance would be applied as applicable to FQHC claims. • FQHCs would continue to be required to meet the FQHC Conditions of

Participation and any additional FQHC payment requirements. • FQHCs cannot bill for CCM services for a beneficiary during the same service

period as billing for transitional care management or any other program that provides additional payment for care management services (outside of the FQHC PPS payment) for the same beneficiary.

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CCM BENEFITS TO THE PATIENTThe patient will experience many benefits from participating in the program:• 24 × 7 access to care coordination• Monthly consultations via non face to face communication such as

telephone• Care Plan progress reviews• The potential to identify escalating conditions before an emergency event

occurs• Improved quality of health by consistent monitoring

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CCM BENEFITS TO THE HEALTH CENTERHealth Centers will also benefit from participating in the program:• Activities are in line with Patient Centered Medical Home and UDS Measure

Quality Improvement initiatives.• Health Centers will receive payment for activities that are already taking

place• Provides level of accountability for follow-up on chronic care patients• Will prepare the Health Center for billing CCM services to Commercial Payers

as available.

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CCM RESOURCESCCM Fact Sheet – All Providers ***** Good source of information****• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdfCMS Care Management Webpage• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeeSched/Care-Management.htmlCCM Services Changes for 2017-Medicare Learning Network• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2017.pdf

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CCM RESOURCESMLN Matters – CCM Services for FQHCs and RHCs - MM9234 Revised• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/MM9234.pdfCCM FAQs for FQHCs as of February 19, 2016• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdfCCM FAQs as of January 18, 2017 – All Providers• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf

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APCA RESOURCES• APCA Training & Technical Assistance Staff

• Patty Linduska pattyl@alaskapca.org• Penney Benson penneyb@alaskapca.org• Lesley de Jaray lesleyd@alaskapca.org• Marie Jackman mariej@alaskapca.org• Suzanne Niemi suzannen@alaskapca.org• Tara Ferguson taraf@alaskapca.org• Tom Taylor tomt@alaskapca.org• Bree Villar breev@alaskapca.org

907-929-2722

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