Hot Topics & Coding for 2017 V4

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1/5/17 Confidential– Donotdistribute

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Confidential– Donotdistribute

HotTopicsInReimbursement2016

BobbiBuellMBA800-795-2633

[email protected]@yahoo.com


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Disclaimer

• Theinformationdescribedhereinissubjecttochangeasmanyofthedetailsofcurrentrulesarenotknown.

• CPTcodesanddescriptionsonlyarecopyright2016AmericanMedicalAssociation(AMA).Allrightsreserved.TheAMAassumesnoliabilityfordatacontainedornotcontainedherein.

• AllMedicareinformationisderivedfrompublishedrules;however,interpretationsmaybeerroneousandtyposmaybeevidenced.Itismandatorythatcodingandbillingisbasedoninformationderivedfromeachpracticeorclinic.

• Thisisnotlegalorpaymentadvice.• ThiscontentisabbreviatedforMedicalOncology.Itdoesnotsubstituteforathoroughreviewofcodebooks,regulations,andCarrierguidance.

• Thisinformationisvalidforthedateofpresentationonly.• Thispresentationshouldnotbereproducedwithoutthepermissionoftheauthorandistimesensitive

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WhereWeAreRightNow:HotTopics

Proposal Current Status NextSteps Date

PartBDrugExperiment ProposedRule FinalRule OVER!

MACRA/MIPS Final Rule None October 14,2016

Physician FeeSchedule Final Rule None November2

Hospital OutpatientPPS FinalRule None November1

ICD-10GracePeriod Final GraceLifted October1

PumpCode MLM Implementation October3

Modifier-JW Transmittal/MLM Implementation January1


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PARTONE:FINALPhysicianFeeScheduleandHospitalOutpatientProspectivePayment2017

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WebSitesfor2017Regulations

• Thispresentationisbasedonpublishedrules• PHYSICIANS:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/

• HOPPS:https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html


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MedicarePhysicianPaymentBasics

•PaymentsarebasedonRVUsforeachcode(WRVUs+PERVUs+MalRVUs)

•RVUsaremultipliedtimesGPCIsforyourgeographicallocation(W*WGPCI+PE*PEGPCI+Mal*MalGPCI)

•TheMedicareconversionfactordeterminestheoveralllevelofMedicarepayments(W*WGPCI+PE*PEGPCI+Mal*MalGPCI)timesCF=$YourTotalAllowableforyourarea

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ConversionFactor2017

*--"Medicare Access and CHIP Reauthorization Act of 2015"

Source: PHYSICIAN Final Fee Schedule 2017


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FeeSchedule:DoesNotIncludeSequestration

• Sequestration:• Medicare2%acrosstheboardstartedonApril1,2013• Impactseverythingincludingdrugs• The2%comesoutoftheMedicareportion(80%)

• Drugsarepaidat104.304%ASP• Allpatientpaymentsexcluded

• Murray-RyanBudgetDealextendedtheSequesteruntil2023;PAMAextendeditto2024,andthelatestbudgetdealextendsitto2025

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99

RevaluedCodes

• Thisisanannualexerciseforcodesregisteringover$10millioninexpenditures.Ifenoughcannotbederivedfromthisprocess,itwillbetakenoutoftheconversionfactor.

• In2017,CMSwillfocusonremovingE/Mfromglobalservices• CMSwilltarget275globalservices• Mustreport99024inthesespecificcasesbyJuly12017:

• Ifthereare≥10providers• IfyouareinKY,LA,NJ,ND,ORE,orRI


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ModerateSedation

• GIcodesandothersconsideredovervaluedbecausemoderatesedationwasintheRVUsandwasbilledforseparately

• Decreaseof.10WorkRVUsforGIprocedures;.25wRVUs forotherprocedures

• Use2017CPTcodes99151-99157fornon-Medicarepayersandfornon-GIservices

• UseG0500,acodespecifictoMedicare,forGIprocedures

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1111

TelehealthServices

• Medicare,livingintheLudditeworld,didnotchangethebasicrulesoftelehealth.

• CMSexpandthelisttoincludethefollowingtelehealthservices:• AdvanceCarePlanning(99497-99498)• ESRDHomeDialysis(90967,90968,90969,and90970)• CriticalCareevaluationandmanagementusingG-codesG0508andG0509,whichwillbeRVUsof4.0and3.86respectively

• TherewillbeanewPlaceofServicecodefortelehealth


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GPCIs

• It’sallaboutCalifornia!• Newlocalitydefinitions• ThesewillbedividedupforfeeschedulepurposesoneitherMetropolitanStatisticalAreas(MSAs)orrestofstate

• Thiswillbephasedin

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1313

ChangestoDigitalImaging

• CMSperceivesthatmostimagingistransitionedfromfilmtodigitalimaging.Thus,theConsolidatedAppropriationsActof2016requireda20%reductiontothe–TCofanX-Rayusingfilm(notdigital)

• Modifier–FXwillberequiredonX-Raysusingfilm• Theremaybereductionstodigitalimagingatsomepoint,butnotin2017


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Mammography

• CPTupdatedandrevisedmammographycodes,eliminatingcodingdifferencesbetweenfilmanddigitalimaging

• Medicarenotusingthesecodesin2017• DevelopedalistofG-codestobeusedfor2017;willuseCPTin2018

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1515

MPPRandtheOPPSCap

• TheConsolidatedAppropriationsActof2016madetheserevisionstotheMultipleProcedureReductiononAdvancedImaging

• Willgofrom25%to5%onthe-26(theprofessionalcomponent)onJanuary1,2017


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PaymentforPrimaryCareandCognitiveSpecialties

PaymentforPrimaryCare&OtherCognitiveSpecialties

PrimaryCareandCare

Coordination

MentalandBehavioralHealth

CognitiveImpairmentAssessment&Planning

CaringforMobility-Related

Impairments

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1717

CognitiveServices

• Paymentforunpaidandnewservices• Paymentfornon-FTFProlongedServices99358-99359• NewG-codesforforadditionalPrimaryCareandCareCoordinationServices• CMSaddsacodeforcaringforpatientswithcognitiveimpairment• CMSwillpayforComplexChronicCareManagement• CMSadds4newcodesforbehavioralhealthintegrationservicescoordinatingprimarycarewithpsychiatry

• Whichwillyouuse?


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Paymentfor2017ServicesCode# Descriptor 2017Non-Facility$ Facility$

99358 ProlongedServicesNon-FTF $113.41 $113.41

99359 ProlongedServicesNon-FTF $54.55 $54.55

99487 ComplexChronicCareW/OVisit $93.67 $52.76

99489 ComplexChronicCareEa Add $47.01 $26.56

G0506 AssessmentforCCMCarePlan $63.88 $46.30

G0505 AssessmentforCognitiveImpairment $238.30 $178.01

G0501 Mobility-Related ImpairmentAssessment

$00.00 $00.00

G0502-G0504,G0507

PsychCareManagement $48-142.84 $46-90.08

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AppropriateUseCriteriaforAdvancedImaging

• TheimplementationdatehasbeendelayeduntilJanuary1,2018

• CMSproposedrequirementsforClinicalDecisionSupportMechanisms,electronictoolstogaugetheclinicalappropriatenessofimaging,e.g.NCCN


2020

MedicareAdvantageProposals

• ProvidersmustbeenrolledinMedicaretoserviceMApatients—ifnottheMAPlanmayfacesanctions

• MAPlansmaynotpayproviderswhoareexcludedbytheOIGortheMedicareProgram

• TheMAPlanwouldberequiredtonotifythepatientthattheproviderwillnotbepaid

• Thiswillbegin2yearsfromthedateoftheFinalRule

• MedicareAdvantagePartDbidswillbepublished

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DiabetesPreventionPrograms

MedicareDiabetesPreventionProgram

Model(2018)

• TheDiabetesPreventionProgrammodelisaservicedeliverytestedbyCMMI withthegoalofpreventingtheonsetofdiabetesinhighriskindividuals

•CMSproposestoexpandthismodelanddesignateitasanadditionalpreventativeservice

DiabetesSelf-Management

Training

•Recentdatarevealsthatonly5%ofMedicarebeneficiariesusetheseserviceswhentheyarediagnosedwithDM•CMSisveryconcernedwiththeutilizationofcodesG0108-G0109forDiabetesSelf-Management•Theywantcommentsonwhy


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HOSPITALOUTPATIENTRULE2017

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2323

Section603:SiteNeutralPolicy

• CMSwillimplementSection603oftheBipartisanBudgetActof2015,whichrequiresthat:

• WiththeexceptionofEmergencyDepartment(“ED”)itemsandservices,• All“NEW”off-campusprovider-baseddepartments(”PBDs”),meaningthosethatstartedbillingunderOPPSon/afterNovember2,2015would:

• Nolongerbecoveredhospitaloutpatientservices• BepaidunderotherPartB‘applicablepaymentsystem’• StartingJanuary1,2017


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ImplementationofSection603

• CMSwillimplementSection603by• Defining”excepteditemsandservices”asthosethatare‘excepted’orexcludedfromthesiteneutralpaymentandwillstillbepaidasofJanuary1,2017.

• Defining‘off-campusPBDs’andproposingrequirementsthatallowcertainoff-campusdepartmentstoretain‘excepted’status

• Establishingpaymentfornon-excepteditemsandservices

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Section603:ExceptedItemsandServices

• “ExceptedItemsandServices”include:• ItemsandservicesbilledinadedicatedED,whetherornottheyareemergencyservices

• ItemsandservicesthatmeetALLofthesecaveats:• Aprovider-baseddepartmentthatbilledunderHOPPSbeforeNovember2,2015,• ItemsandservicesfurnishedattheSAMELOCATIONtheprovider-baseddepartmentfurnishedservicesatasofNovember2,2015,unless

• SomethingcatastrophichappenstoyourfacilityandCMSallowsittobeexcepted


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• On-campushospitallocations• Allon-campus PBDsanditemsandservicesthattheyfurnishareEXCEPTEDfromthesite-neutralpaymentreductions

• On-campusisdefinedusingMedicare,42CFR413.65definition:• Thephysicalareaimmediatelyadjacenttotheprovider’smainbuildings,locatedwithin250yardsofthemainbuildings,andotherarea’sdeterminedonacase-by-casebasisbyCMSRegionalOffices.

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• RelocationofExceptedOff-campusPBDs• Tobeexcepted,thePBDmustmaintainthesamephysicaladdressithadasofNovember1,2015—andthatincludestheunitnumber

• Anyrelocationwouldresultinthelossof‘excepted’status• CMSwillallowfacilitiestobeexceptedonlimitedexceptions,extraordinarycircumstances


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Section603:PaymentSystem

• Section603requiresthatpaymentunderanotherPartB“applicablepaymentsystem”beusedfornon-exceptedPBDs

• IntheFinalRule,CMSoptednottoimplementthispaymentpolicyexactlyasproposed,exceptthatprofessionalserviceswillbebilledastheyarenow

• Instead,CMSwillpaythehospitalaratethatisapproximately50percentoftheOPPSrate,withsomelimitedexceptions.ItemsandservicesthatarecurrentlypaidunderamethodologyotherthanOPPSwillcontinuetobepaidatthecurrentlyapplicablenon-OPPSpaymentsystemorrate(e.g.,drugsandbiologicalsthatareseparatelypayablewillcontinuetobepaidASP+6%,andwillnotbesubjecttothisreduction).

• Hospitalswillusemodifier“PN”toidentifyservicesatnon-grandfatheredentities.Paymentsunderthenewmethodologywillbesubjecttoageographicadjustmentandthemultipleprocedurepaymentadjustment,butotherOPPSpaymentadjustments(e.g.,outlierpayments,solecommunityhospitaladjustments,cancerhospitaladjustments)willnotapply.Becauseofthisnewpaymentpolicy(andothertechnicaladjustmentstothecalculations),CMSrevisedthepaymentimpactoftheSection603policiesfromareductioninpaymentfor2017from$330millionto$50million

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FinalizedPaymentUpdateforAPCs

Source: American Association of Medical Colleges


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OPPSPaymentAdjustments

• WageIndex• WilluseInpatientFinalRuleWageIndex• OPPSwageadjustmentwillbeappliedto60%oftheAPCrate

• SoleCommunityHospitalsandEssentialAccessCommunityHospitalswillgeta7.1%increasewhichexcludesdrugsanddevices

• InflationAdjustmentforExcessPackagedPaymentsduetoLaboratoryTests:OPPSspendingforCY2014experienceddouble-digitgrowth,comparedtoatypicalannualincreaseof6-8%.ThiswasduetoCMS’policyofpackaginglaboratoryservicesintoOPPSpaymentweights,withoutimplementingacomparablereductioninspendingforlaboratoryservicesthatcontinuedtobepaidattheclinicallaboratoryfeeschedule(CLFS).Inordertoaddresstheincreasedpaymentsresultantofthis,CMSisadoptingaprospectivereductionof2.0%totheCY2016OPPSconversionfactor.

• CancerHospitalswillcontinuetoreceivepaymentincreasesina‘budgetneutral’manner

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3131

OutlierAdjustment

• Tomaintaintotaloutlierpaymentsat1.0%oftotalOPPSpayments,CMShassetafinalCY2016outlierfixed-dollarthresholdof$3,250.

• Thisisanincreasecomparedtothecurrentthresholdof$2,775.Outlierpaymentswillcontinuetobepaidat50%oftheamountbywhichthehospital’scostexceeds1.75timestheAPCpaymentamountwhenboththe1.75multiplethresholdandthefixed-dollarthresholdaremet.


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DrugPayments

• Drugs,unlessthePartBDrugExperimentisineffect,willbepaidatAverageSalesPriceplus6%

• Drugswhosecostis$110orlessperencounter,accordingtoCMS,willbebundledintotheAPC.Thisa$10increasefromlastyear asusual

• Radiopharmaceuticalswillalsohavea$110packagingthreshold

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3333

ComprehensiveAPCs

• ComprehensiveAPCsprovideall-inclusivepaymentsforallservicesthatarelatedtotheprimaryprocedure,whichinclude:

• Diagnosticprocedures• Labtests• Relatedtreatments• Visits/clinicevaluations• Supplies/DMErelatedtoclinictreatment• Bloodandbloodproducts


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ComprehensiveAPCs

• ForCalendarYear2017,therewillbe10newC-APCs.CMSfinalizesthefollowingrelatedtoOncologyandHem-Onc:

• 2C-APCsforBiopsies,ExcisionandDrainage(5072-5073)• 3C-APCSforBreast/LymphaticSurgeryandRelatedProcedures(5091,5092,and5094)

• Level4BloodProductExchangeandRelatedServices(APC5244)• FinalizedproposalforanewcostcenterandC-APCforbonemarrowtransplants

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3535

LaboratoryPackaging

• Currentlyalabtestisnotpackagedif:• Itistheonlyserviceontheclaim• IthasanL1modifier,signifyingthatitisunrelatedtobilledAPCs• Itismolecularpathology• Itisapreventivetest

• Changesfor2017:• Discontinuetheunrelatedtestprovision• Bundlealltestsdoneasbilledonthesameclaim• Expandthemolecularpathologyexceptiontoincludealladvanceddiagnosticlabtests(ADLTs)asdefinedbyCMS


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ChangestoPaymentforFilmX-Ray

• LikeinthePhysicianFinalRule,thisisimplementationofofConsolidatedAppropriationsActof2016:

• CY2017andbeyond—ReducesOPPSpaymentsBY20%forX-RaysdoneusingFILMandthehospitalmustuse-FX

• CY2018-2022:ReducesOPPSpaymentsby7%forX-Raysdoneusingcomputedradiography

• CY2023andbeyond:ReducesOPPSpaymentby10%forX-RaysusingcomputedRadiography

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HospitalOutpatientQualityReporting

• Thisyear,thesetwoclaims-basedmeasureswereaddedandwillbecalculatedbyCMS:

• OP-35:AdmissionsandEDVisitswithin30daysofOutpatientChemotherapy

• Excludesleukemia• ChemoshouldbedoneinthesameHOPD

• OP-36:HospitalVisitswithin7daysofoutpatientsurgery


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HospitalOutpatientCCM

• PaymentforChronicCareManagementServices(FRpages70,450– 70,453):CMSisadoptingadditionalrequirementsforhospitalstobillandreceivepaymentforCPTcode99490(“Chroniccaremanagementservices(CCM),atleast20minutesofclinicalstafftimedirectedbyaphysicianorotherqualifiedhealthcareprofessional,percalendarmonth”).Theprimarypointsofthischangeare:

• Thepatientmusthaveregisteredtothehospitalaseitheraninpatientoroutpatientwithinthelast12months,andforwhomthehospitalprovidedtherapeuticservices;

• Thehospitalisrequiredtohavedocumentedinthemedicalrecordthattheserviceswereexplainedandofferedtothebeneficiary,andthatthebeneficiaryeitheragreedtoordeclinedtheservices;orthatthisagreementisprovidedinamedicalrecordaccessibletothehospital;

• Thatduringasinglecalendarmonthserviceperiod,onlyonehospitalmayfurnish,andbepaid,forthoseservicesdescribedbyCPTcode99490;and

• Thatadditionalrequirementslistedonpage70,452oftheFRbeprovided;includingtherecordingofdemographicsandpotentialcomplications,full-timeaccesstocaremanagementservices,thattherebecontinuityofcareforanyroutineappointmentstofollow,andarequirementfortheuseofEHRtechnology.

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DrugAdministration—U.S.Averages

Code Descriptor 2016PFS 2017PFS 2016APC 2017 APC

96361 Sequentialhydration $15.40 $15.43 $30.87 $34.89

96367 Sequentialtherapeuticinfusion $30.79 $31.22 $42.31 $52.69

96372 Therapeutic injection $25.42 $25.84 $42.31 $52.69

96413 Chemotherapy infusion,initial $139.41 $139.61 $280.27 $280.41

96417 Chemotherapyinfusion,sequential

$63.02 $66.04 $42.31 $52.69


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INTRODUCTIONTOMIPS:FINALRULE

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4141

CreationandDemolitionoftheSGR

• The sustainable growth rate (SGR) was created by theBalanced Budget Act of 1997 as a means to control Medicarespending by tying Medicare clinician payments to increasesin the gross domestic product (GDP).

• When health spending outpaced GDP, negative paymentupdates were threatened as a result.

• Due to the inability to find sufficient offsets, the SGR wasunable to be repealed for nearly two decades.

Congresspassed17patchestoavoidcuts(implementingcutstwice)


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The“Lost”Years…2015-2018

• Until12/2018providersstillsubjecttopenalties/bonusesofValueBasedPaymentModifier(VBM),MeaningfulUse(MU)andPhysicianQualityReportingSystem(PQRS)

• Themaximumpenaltyduringtheseyearsgrowsfrom3.5%in2015to11%in2018

• FromJuly2015-December2019MACRAprovidesayearly0.5%paymentupdatetotheMedicarePhysicianFeeSchedule


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DifficultforSmallPracticesandSomeSpecialties

WinnersPositive

AdjustmentCardiology 62.1%

Endocrinology 67.3%

Emergency Medicine 64.0%

Colorectal Surgeons 59.7%

Family Practice 59.5%

Gastroenterology 61.5%

Nurse Practitioners 62.0%

Pediatrics 79.3%

LosersNegative

Adjustments

Chiropractors -98.4%

Dentists -68.9%

General Practice -69.4%

Optometry -79.7%

Podiatry -78.0%

Plastic Surgery -65.4%

Psychiatry -68.8%

Physical Medicine -57.9%

Source CMS MACRA Proposed Rule, Table 63, pages 672-675

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AlternativePaymentModels—Year1

ThefinalruleincludesapreliminarylistofmodelqualitiesthatwouldqualifyunderthetermsoftheAdvancedAPMs.AdvancedAPMsmustmeetthefollowingrequirements:ü ü BeCMSInnovationCentermodels,SharedSavingsProgramtracks,orcertain

federaldemonstrationprogramsü ü Requireparticipantstousecerti ed EHRtechnologyü ü BasepaymentsforservicesonqualitymeasurescomparabletothoseinMIPSü ü BeaMedicalHomeModelexpandedunderInnovationCenterauthorityorrequire

participantstobearmorethannominalfinancialriskforlosses.

ThefinalrulewithcommentperioddefinedtheriskrequirementforanAdvancedAPMtobeintermsofeithertotalMedicareexpendituresorparticipatingorganizations’Medicarerevenue(whichmayvarysignificantly).ThisenhancedflexibilityallowsforthecreationofmoreAdvancedAPMstailoredtophysiciansandotherclinicians,suchasadvancedpracticenurses,generally,andsmallpracticeparticipationinparticular.


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RequiredParticipationinAPMs

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CurrentAdvancedAPMs

ComprehensiveESRDCareModel

(13ESCOs)

ComprehensivePrimaryCarePlus(14states,practiceapplicationsclosed

9/15/16)

MedicareSharedSavingsTrack2(6ACOs,1%oftotal)

MedicareSharedSavingsTrack3

(16ACOs,4%oftotal)

NextGenerationACOModel(currently18)

OncologyCareModelTrack2(Aportionof196

practiceswillqualify)

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AdvancedAPMsfor2018

• In2018,CMSanticipatesthatcliniciansmayalsoearntheincentivepaymentthroughsufficientparticipationinthefollowingnewandexistingmodels:

• MedicareACOTrack1+Model• Newvoluntarybundledpaymentmodel• ComprehensiveCareforJointReplacementPaymentModel(CertifiedElectronicHealthRecordTechnology(CEHRT)track)

• AdvancingCareCoordinationthroughEpisodePaymentModelsTrack1(CEHRTtrack)

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Merit-BasedIncentivePaymentSystem

MIPS

Quality(PQRS)

Advancing CareInformation

ResourceUse(ValueModifier)

ClinicalPracticeImprovement

• Individualprogramscontinuethrough2018

• 2016performanceyear• MIPSbeginsin2019forphysiciansandmostmid-levelclinicians

• 2017performanceyear• Eligibleprofessionalsscoredagainstbenchmarkbasedonprioryear’sperformance

• Low-volumeprovidersandsomeAPMparticipantscanbeexemptfromMIPSrequirements


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FlowofEvents

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HowCanYouParticipatein2017?


5252

• ReportsomedataatanypointinCY2017todemonstratecapability• 1qualitymeasure,or 1improvementactivity,or 4/5requiredACImeasures

• Nominimumreportingperiod• Nonegativeadjustmentin2019

MIPSTesting

• SubmitpartialMIPSdataforatleast90consecutivedays• 1+qualitymeasure,or 1+improvementactivities,or 4/5requiredACImeasures

• Nonegativeadjustmentin2019• Potentialforsomepositiveadjustment(<4%)in2019

PartialMIPSreporting

• Meetallreportingrequirementsforatleast90consecutivedays• Nonegativeadjustmentin2019• Maximumopportunityforpositive2019adjustment(< 4%)• Exceptionalperformerseligibleforadditionalpositiveadjustment(upto10%)

FullMIPSreporting

• NoMIPSreportingrequirements(APMshavetheirownreportingrequirements)• Eligiblefor5%advancedAPMparticipationincentivein2019

AdvancedAPMparticipation

PICKYOURPACE:2017TRANSITIONALPERFORMANCEREPORTINGOPTIONS

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The only physicians who will experience negative payment adjustments (-4%) in 2019 are those who report no data in 2017

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5353

MIPSAdjustment/Bonuses

• BasedoncompositeperformancescoreEPsmayreceiveanupward,downwardornopaymentadjustment

• ExceptionalPerformersseesignificantopportunitiesforadditionalbonuses/adjustmentsontopoftraditionalMIPSincentives

• Availablein2019through2024

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5454

ActualFinalRuleScoringYear1

Category2017—YEAR1—FINALRULEOctober14,2016 QPP%

QUALITY:Mostparticipants:Reportupto6qualitymeasures,includinganoutcomemeasure,foraminimumof90days.Groupsusingthewebinterface:Report15qualitymeasuresforafullyear.GroupsinAPMsqualifyingforspecialscoringunderMIPS,suchasSharedSavingsTrack1ortheOncologyCareModel:ReportqualitymeasuresthroughyourAPM.YoudonotneedtodoanythingadditionalforMIPSquality.TheOncologyMeasuresGroupisgone!

60%

IMPROVEMENT ACTIVITIES:Mostparticipants:Attestthatyoucompletedupto4improvementactivitiesforaminimumof90days.Groupswithfewerthan15participantsorifyouareinaruralorhealthprofessionalshortagearea:Attestthatyoucompletedupto2activitiesforaminimumof90days.Participantsincertifiedpatient-centeredmedicalhomes,comparablespecialtypractices,oranAPMdesignatedasaMedicalHomeModel:Youwillautomaticallyearnfullcredit.GroupsinAPMsqualifyingforspecialscoringunderMIPS,suchasSharedSavingsProgramTrack1orOncologyCareModel:YouwillautomaticallyreceivepointsbasedontherequirementsofparticipatingintheAPM

15%

ADVANCINGCAREINFORMATION:Fulfilltherequiredmeasuresforaminimumof90days:ü SecurityRiskAnalysisü e-Prescribingü ProvidePatientAccessü SendSummaryofCareü Request/AcceptSummaryofCareChoosetosubmitupto9measuresforaminimumof90daysforadditionalcredit.ORYoumaynotneedtosubmitAdvancingCareInformationifthesemeasuresdonotapplytoyou.

25%

COST Startsin2018

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5555

WaytoSelectMeasures(qpp.cms.gov)


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MIPS:WhoIsEligible

• Years1-2:• MD/DO• Physician’sAssistants• NursePractitioners• ClinicalNursePractitioners• CRNA’s

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WhoIsExcluded

• Newclinicianswhohavebilledtheprogram≤1year

• Lowvolumephysicianswhobill<$30,000toPartBANDhave≤100patients

• Hospitalsandotherfacilities• ParticipantsinAdvancedAPMsaswedefinedpreviously


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HowDoISubmit?

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HowDoISubmit?


6060

MACRAPaymentAdjustments

2015 2016 2017 2018 2019 2020 2021 2022+PQRS+VM+EHR Adjustments(combined)

~+ 5%3.5%

TBD- 6%

TBD-9%

TBD-10% or more

TBD-11% or

more

TBD-11% or

more

TBD-11% or

more

TBD-11% or

more

MIPS Bonus/Penalty (max)

+4%*

-4%+5%*

-5%+7%*

-7%+9%*

-9%

APM Bonus+5% +5% +5% +5%

* May be increased by up to 3 times to incentivize performance$500 mil funding for bonuses allocated through 2024

Benchmark

Neutral Adjustment

High Performance

Positive Adjustment

Low Performance

Negative Adjustment

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MeasureDevelopmentPlan&Funding

ByJan2016

• HHSSecretaryandstakeholdersmustdevelopandpublishadraftplanforMIPSandAPMmeasuredevelopment

ByMar2016• Closeofpubliccommentperiod

ByMay2016• FinalplanpublishedonHHSwebsite

May2017&beyond

• Annualprogressreport,includingalistingofeachmeasuredevelopedorindevelopment

• $15mileachfiscalyear2015to2019• Prioritizemeasuregaps

• outcome,patientexperience,carecoordination,andappropriateusemeasures

• Incorporationofprivatepayeranddeliverysystemmeasures

• Coordinationacrossstakeholders• Utilizationofclinicalbestpracticesandpracticeguidelines


6262

2016ValueModifierResultsCY2014Performance

LowQuality

AverageQuality

HighQuality

LowCost 6 73 0 79

AverageCost 644 7,351 55 8,090

HighCost 39 226 1 266

689 7,650 56

Groups with 10 or more eligible professionals

5,418didnotreportPQRS!

+15.9%1x+31.8%2x

-2%

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63

CODING2016-2017


6464

BillingWith-JW

• EffectiveJanuary3,2017,allMedicaredrugclaimsforsingledosevials(SDVs)mustreflecttheamountofdrugwasted:

• Twolines—oneforthedrugused;theotherfortheamountwastedwithModifier–JW

• Exception:whentheJ-codeunitexceedstheamountgivenpluswastage• Wastagemustbedocumentedintherecordwithtime,date,amountgiven,andamountwasted

• Everyeffortshouldbemadetominimizewastage

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6565

Modifier–JWAndMore

• EffectiveOctober1,CIGNAisrequiring–JW• TheyarealsorequiringNDCcodes• EffectiveJanuary1,2017,UnitedHealthcarewillrequireNDCs


66

CODINGSPECIFICITY?

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6767

WhatWasTheMedicareICD-10-CMFlexibilityPeriod?

• Therewouldbenodenialsforcodesthatarevalidforlackofspecificityiftheyareintheright3-charactercategoryforoneyearWHICHISNOWOVER

• AnexampleisC81(Hodgkin’slymphoma)– whichbyitselfisnotavalidcode.ExamplesofvalidcodeswithincategoryC81contain5characters,suchas:

• C81.00NodularlymphocytepredominantHodgkinlymphoma,unspecifiedsite• C81.03NodularlymphocytepredominantHodgkinlymphoma,intra-abdominallymphnodes

• C81.10NodularsclerosisclassicalHodgkinlymphoma,unspecifiedsite• C81.90Hodgkinlymphoma,unspecified,unspecifiedsite

• Duringthe12monthafterICD-10implementation,usinganyoneofthevalidcodesforHodgkin’slymphoma(C81.00,C81.03,C81.10orC81.90)wouldnotbecauseforanauditundertheannouncedflexibilities.

• REMEMBERthisonlyappliestoMedicarePARTBclaims—nothospital,MedicareAdvantage,orprivateinsuranceclaims

• BUT,THISISOVER!!!


68

OPDIVO®(nivolumab)Top25DiagnosesQ42016

Diagnosis Description DistinctPatientsDistinctClaimsDaystoFile(NoOutliers)DaystoPay(NoOutliers)TrueDenialPercentC34.11 Malignantneoplasmofupperlobe,rightbronchusorlung 405 1,261 6 23 8.08%C34.90 Malignantneoplasmofunspecifiedpartofunspecifiedbronchusorlung 312 931 6 23 10.43%C34.12 Malignantneoplasmofupperlobe,leftbronchusorlung 286 886 6 23 7.97%C34.31 Malignantneoplasmoflowerlobe,rightbronchusorlung 159 493 7 23 5.74%Z51.12 Encounterforantineoplasticimmunotherapy 169 473 6 22 5.80%C34.32 Malignantneoplasmoflowerlobe,leftbronchusorlung 149 455 7 23 5.89%C64.1 Malignantneoplasmofrightkidney,exceptrenalpelvis 133 417 6 23 4.25%C64.9 Malignantneoplasmofunspecifiedkidney,exceptrenalpelvis 132 401 6 22 8.13%C64.2 Malignantneoplasmofleftkidney,exceptrenalpelvis 133 395 6 23 6.48%C34.10 Malignantneoplasmofupperlobe,unspecifiedbronchusorlung 119 394 5 23 9.96%C43.9 Malignantmelanomaofskin,unspecified 120 359 5 24 7.92%C34.80 Malignantneoplasmofoverlappingsitesofunspecifiedbronchusandlung 84 273 5 22 10.13%C34.2 Malignantneoplasmofmiddlelobe,bronchusorlung 88 263 6 22 6.69%C34.91 Malignantneoplasmofunspecifiedpartofrightbronchusorlung 90 257 7 24 11.96%C34.92 Malignantneoplasmofunspecifiedpartofleftbronchusorlung 88 232 5 23 5.96%Z51.11 Encounterforantineoplasticchemotherapy 118 226 9 28 6.52%C43.59 Malignantmelanomaofotherpartoftrunk 72 216 5 23 13.18%C34.30 Malignantneoplasmoflowerlobe,unspecifiedbronchusorlung 60 188 6 24 7.35%C34.81 Malignantneoplasmofoverlappingsitesofrightbronchusandlung 51 167 6 21 12.45%C43.4 Malignantmelanomaofscalpandneck 52 146 6 23 3.70%C34.02 Malignantneoplasmofleftmainbronchus 35 93 7 25 14.96%C34.82 Malignantneoplasmofoverlappingsitesofleftbronchusandlung 27 84 7 26 20.35%C43.62 Malignantmelanomaofleftupperlimb,includingshoulder 21 67 6 25 17.48%C34.00 Malignantneoplasmofunspecifiedmainbronchus 41 54 5 21 1.33%C43.71 Malignantmelanomaofrightlowerlimb,includinghip 18 54 5 23 3.33%

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69

Avastin®(bevacizumab)Top25DiagnosesQ42016

Diagnosis DescriptionDistinctPatients

DistinctClaims

DaystoFile(NoOutliers)

DaystoPay(NoOutliers)

TrueDenialPercent

C18.7 Malignantneoplasmofsigmoidcolon 418 1,160 6 25 7.49%C20 Malignantneoplasmofrectum 415 1,132 7 26 5.58%C18.9 Malignantneoplasmofcolon,unspecified 372 1,073 6 24 6.28%C18.2 Malignantneoplasmofascendingcolon 277 793 7 28 7.63%C56.9 Malignantneoplasmofunspecifiedovary 235 608 6 24 3.79%Z51.11 Encounterforantineoplasticchemotherapy 259 547 8 27 5.83%C18.0 Malignantneoplasmofcecum 159 461 6 26 5.42%C18.4 Malignantneoplasmoftransversecolon 99 275 6 26 6.23%Z51.12 Encounterforantineoplasticimmunotherapy 135 262 7 29 7.08%C18.6 Malignantneoplasmofdescendingcolon 92 259 7 27 8.60%C34.12 Malignantneoplasmofupperlobe,leftbronchusorlung 107 252 6 27 7.88%C34.90 Malignantneoplasmofunspecifiedpartofunspecifiedbronchusor 113 242 7 25 10.34%C19 Malignantneoplasmofrectosigmoidjunction 79 232 5 28 5.73%C34.11 Malignantneoplasmofupperlobe,rightbronchusorlung 112 222 5 23 5.93%C56.1 Malignantneoplasmofrightovary 89 222 7 29 7.14%C71.9 Malignantneoplasmofbrain,unspecified 76 184 4 20 2.39%C18.1 Malignantneoplasmofappendix 62 164 6 22 6.04%C34.31 Malignantneoplasmoflowerlobe,rightbronchusorlung 68 138 5 29 10.98%C18.8 Malignantneoplasmofoverlappingsitesofcolon 46 136 6 23 7.11%C56.2 Malignantneoplasmofleftovary 52 125 7 25 11.76%C71.1 Malignantneoplasmoffrontallobe 40 122 6 21 0.65%C34.32 Malignantneoplasmoflowerlobe,leftbronchusorlung 59 121 6 27 4.26%C34.91 Malignantneoplasmofunspecifiedpartofrightbronchusorlung 56 116 6 25 13.57%C18.3 Malignantneoplasmofhepaticflexure 35 103 8 27 6.87%


70

NewBehavioralHealth&CareCoordinationcodesMedicareFeeSchedule

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7171

WhoQualifiesforTheseCodes?

• TheCoCM servicescanbefurnishedwhenthebeneficiaryhasoneormorepsychiatricorbehavioralhealthconditions(includingsubstanceabusedisorders)that,inthetreatingphysician’sjudgment,warrantabehavioralhealthcareassessment,acareplan,andbriefinterventions.Initscommentary,CMSelaboratedonseveralkeypoints:

• Thepatientmustpresentwithapsychiatricorbehavioralhealthconditionthat,intheclinicaljudgmentofthetreatingphysician,warrantsreferraltothebehavioralhealthcaremanagerforfurtherassessmentandtreatmentthroughCoCMservices.

• Thediagnosismaybepre-existingorestablishedbythetreatingphysician.• TheCoCM codesarenotlimitedtoaparticularsetofbehavioralhealthconditions.

• TheCoCM codescanonlybereportedbyatreatingphysicianwhodirectsthebehavioralhealthcaremanagerandoverseesthebeneficiary’scare.Thephysicianmustremaininvolvedinongoingoversight,management,collaboration,andassessmentforthedurationofthetimethatheorsheisreportingit.CMSexpectsmostCoCM servicestobeperformedbyprimarycarepractitioners,butrecognizesthattheCoCM codescanalsobebilledinothermedicalspecialtysettingswhenthephysicianmanagesthebeneficiary’sbehavioralhealthandotherconditions


7272

BehavioralHealthManagement

• G0502 – First70minutesinthefirstcalendarmonthforbehavioralhealthcaremanageractivities,inconsultationwithapsychiatricconsultantanddirectedbythetreatingprimarycareprovider.Mustinclude:

• · Outreachandengagementofpatientsdirectedbyaprimarycareprovider;

• · Initialassessment,includingadministrationofvalidatedscalesandresultinginatreatmentplan;

• · Reviewbypsychiatricconsultantandmodifications,ifrecommended;• · Enteringpatientsintoaregistryandtrackingpatientfollow-upandprogress,andparticipationinweekly

• caseloadreviewwithpsychiatricconsultant;and• · Provisionofbriefinterventionsusingevidence-basedtreatmentssuchasbehavioralactivation,problem- solvingtreatment,andotherfocusedtreatmentactivities.

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7373

BehavioralHealthManagement

• G0503 – first60minutesinasubsequentmonthofbehavioralhealthcaremanageractivities.Mustinclude:

• · Trackingpatientfollow-upandprogress;• · Participationinweeklycaseloadreviewwithpsychiatricconsultant;• · OngoingcollaborationandcoordinationwithPCPandanyothertreatingproviders;

• · Ongoingreviewbypsychiatricconsultantandmodificationsbasedonrecommendations;

• · Provisionofbriefinterventionsusingevidencebasedtreatments;• · Monitoringofpatientoutcomesusingvalidatedratingscales;and• · Relapsepreventionplanningandpreparationfordischargefromactivetreatment.

• G0504 – eachadditional30minutesinacalendarmonthofbehavioralhealthcaremanageractivitieslistedabove.

• · ListedseparatelyandusedinconjunctionwithG0502andG0503.


7474

BehavioralHealthManagement(G0502-G0504)

• TheCMSfinalrulestatesthatthebehavioralhealthcaremanagershouldhaveacademicandspecializedtraininginbehavioralhealth,butneednotbelicensedtobilltraditionalpsychotherapycodesforMedicare

• Behavioralhealthcaremanagers(BHCMs)qualifiedtobilltraditionalpsychiatricevaluationandtherapycodesforMedicarerecipientsmaybillforadditionalpsychiatricservicesinthesamemonth.However,timespentbytheBHCMonactivitiesforservicesreportedseparatelymaynotbeincludedintheservicesreportedusingtimeappliedtoG0502,G0503,andG0504.

• Thepsychiatricconsultantmayalsofurnishface-to-faceservicesdirectlytothepatientbut,liketheBHCM,thetimemaynotbebilledusingmultiplecodes.Thisismucheasiertodemarcateforthepsychiatricconsultant,giventhattheydonotseethepatientface-to-faceintheircollaborativecareconsultingrole.

• Youmustenterthepatientinaregistryandtrackpatientfollow- upandprogressusingtheregistry,withappropriatedocumentationandparticipationinaweeklyconsultationwiththepsychiatricconsultant

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7575

WhatisaBehavioralHealthCareManager?

• The behavioralhealthcaremanagermusthaveformaleducationorspecializedtraininginbehavioralhealth.CMSrecognizessocialwork,nursingandpsychologyasacceptabledisciplines.Theresponsibilitiesofthebehavioralhealthcaremanagerinclude:

• Providingthefollowingelementsofserviceinconsultationwiththepsychiatricconsultant:

• Caremanagementservicesandassessmentofneeds• Behavioralhealthcareplanning,includingmanagingtreatmentplanrevisionsforpatientswhoarenotprogressingorwhosestatuschanges

• Briefinterventions• Ongoingcollaborationwiththetreatingphysician• Registrymaintenance• Consultingwiththepsychiatricconsultantonaweeklybasis• Maintainingacollaborative,integratedrelationshipwiththecareteammembers• Maintainingtheabilitytoengagethebeneficiaryduringoffhoursandhaveacontinuousrelationshipwiththebeneficiary


7676

BehavioralHealthCareManagement

• G0507 – Caremanagementservicesforbehavioralhealthconditions,atleast20minutesofclinicalstafftimepercalendarmonth.Mustinclude:

• · Initialassessmentorfollow-upmonitoring,includinguseofapplicablevalidatedratingscales;

• · Behavioralhealthcareplanninginrelationtobehavioral/psychiatrichealthproblems,includingrevisionforpatientswhoarenotprogressingorwhosestatuschanges;

• · Facilitatingandcoordinatingtreatmentsuchaspsychotherapy,pharmacotherapy,counselingand/orpsychiatricconsultation;and

• · Continuityofcarewithadesignatedmemberofthecareteam.

• G0507 canonlybereportedbyatreatingprimarycareproviderandcannotbeindependentlybilled.ForG0507,abehavioralhealthcaremanagerwithformalorspecializededucationisnotrequired.CMSrulesallow“clinicalstaff”toprovideG0507servicesusingthesamedefinitionof“clinicalstaff”asappliedundertheChronicCareManagementbenefit.

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7777

AssessmentofCognitiveImpairment

• G0505--NewcodeG0505willcoverassessmentandcareplanningforpatientswithcognitiveimpairment,suchasAlzheimer’sdiseaseordementia,ifthefollowingelementsaresatisfied:

• Cognition-focusedevaluationincludinghistoryandexamination• Moderateorhighcomplexitymedicaldecision-making• Functionalassessment,includingdecision-makingcapacity• Useofstandardizedinstrumentstostagedementia• Medicationreconciliationandreviewforhigh-riskmedications(ifapplicable)• Evaluationforneuropsychiatricandbehavioralsymptoms,includingdepression• Evaluationofsafety,includingmotorvehicleoperation• Identificationofcaregiver(s),caregiver’sknowledge,caregiver’sneeds,socialsupport,andcaregiver’swillingnesstogivecare

• Advancecareplanningandpalliativecareneeds• Creationandsharingofacareplanwith

• AllofthespecifiedelementsunderG0505mustbeperformedbythebillingphysicianorNPP


78

CareCoordinationCodesMedicareFeeSchedule2017

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7979

CareCoordinationCodes

• CPT99490—Chroniccaremanagementservices,atleast20minutesofclinicalstafftimedirectedbyaphysicianorotherqualifiedhealthcareprofessional,percalendarmonth,withthefollowingrequiredelements:

• Multiple(twoormore)chronicconditionsexpectedtolastatleast12months,oruntilthedeathofthepatient;

• Chronicconditionsplacethepatientatsignificantriskofdeath,acuteexacerbation/decompensation,orfunctionaldecline;

• Comprehensivecareplanestablished,implemented,revised,ormonitored

• Aspartofthechangestakingeffectin2017,CMShassaidtheywill“appropriatelyrecognizeandpayfor”othercomplexchroniccaremanagementCPTcodesincludingCPT99487andCPT99489.


8080

ChangestoCCM

• CMSalsochangedtherequiredserviceelementsthatmustbeinplaceinordertobillforanychroniccaremanagementservice.Specifically,revisionsweremadetosixserviceelementsincluding:

• Initiatingvisit• 24/7accesstocareandcontinuityofcare• Comprehensivecareplan• Managementofcaretransitionsdocumentation• Homeandcommunity-basedcarecoordination• Beneficiaryconsent

• Formoreinfo,seehttp://www.capturebilling.com/chronic-care-management-coding-guidelines/

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8181

InitiatingChronicCareManagement

• CPTG0506—Comprehensiveassessmentofandcareplanningbythephysicianorotherqualifiedhealthcareprofessionalforpatientsrequiringchroniccaremanagementservices(billedseparatelyfrommonthlycaremanagementservices)(Add-oncode,listseparatelyinadditiontoprimaryservice).

• Thiscodeistobebilledforbeneficiariesrequiringextensiveface-to-faceassessmentandface-to-faceornon-face-to-facecareplanning.Forthiscode,theassessmentandplanningisconductedbythephysician instead oftheclinicalstaffasisthecaseforCPTcodes99487,99489,and99490.

• Inadditiontobillingfortheinitiatingvisit(whichcouldbeanE/M,AWV,orIPPE),thephysicianshouldalsobillCPTG0506forthecomprehensiveassessmentandplanning.

• G0506mayonlybebilledonceperbeneficiary,inconjunctionwiththestartorinitiationofCCMservices.CPTcodes99487,99489,and99490maybebilledwithG0506,assumingthebillingrequirementsaremet.

• CMSdevelopedthisnewadd-onG-codeto“improvepaymentforservicesthatqualifyasinitiatingvisitsforCCMservices.”


8282

ComplexChronicCareManagement(99487,99489)

• ExistingCPTcodes99487,99489• Statusindicatorchangedfrombundled toactive byCMSforJanuary12017

• BilltoCPTdescriptor• Paysforclinicalstafftimedirectedbyphysicianorotherqualifiedhealthcareprofessional

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8383

ComplexChronicCareManagement

• Atleast60minutesstafftimeinacalendarmonth• Establishmentorsubstantialrevisionofcomprehensivecareplan;medical,functionaland/orpsychosocialproblemsrequiringmoderateorhighmedicaldecision-making;underthedirectionofaphysicianorqualifiedhealthcareprofessional

• Donotreportifcareplanisunchangedorminimallychanged—itwouldnotmakesenseforthisamountoftime


8484

Non-FTFProlongedServices

• 99358-99359--CMSismakinggoodonaproposaltoallowseparatepaymentsfor

• 99358 (Prolongedevaluationandmanagementservicebeforeand/orafterdirectpatientcare;firsthour)and

• 99359 (Prolongedevaluationandmanagementservicebeforeand/orafterdirectpatientcare;eachadditional30minutes[Listseparatelyinadditiontocodeforprolongedservice]).ThosecodeswerepreviouslybundledwithotherE/Mcodes.

• ThisisforaphysicianorNPPtime,notforstafftime• MaynotbebilledinthesamemonthasCCMorTCM

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85

HCPCSCODESJANUARY1,2017


8686

CPT2017

•96377—Applicationofon-bodyinjector(includescannulainsertion)fortimedsubcutaneousinjection

• FORPRACTICES--Thereisnofeescheduleamount.ThiswillbeCarrier-pricedandshouldbetiedbackto96372

• Checkwithpayersbeforebilling• StatusintheHOPD—Status“N”--PaidunderOPPS;paymentispackagedintopaymentforotherservices.Therefore,thereisnoseparateAPCpayment.

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8787

HCPCSAdded


88

HCPCSChanges(Drugs)

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89

HCPCSDeletions


90

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Hot Topics & Coding for 2017 V4