Prescription drug management and medical decision making (MDM)

The Documentation Guidelines identify three key components in E/M services: history, exam and medical decision making. MDM itself is divided into three components: the number of diagnoses or management options, the amount and/or complexity of data to be reviewed and the risk of significant complications, morbidity and/or mortality. Not stopping there, this table of risk is divided into three sections: the presenting problem, diagnostic procedure(s) ordered and management options selected. Prescription drug management appears in the management options column of the table of risk and is indicated as “moderate.”

Simple, isn’t it? If prescription drug management is selected as the management option, the table of risk indicates moderate. (Of course, to select MDM, you need two of three of the number of diagnoses/treatment options considered, amount of complexity and selection from the table of risk.)

But, considering prescription drug management, the table of risk does not have any qualifications. It doesn’t say, “new prescriptions, not renewals.” It doesn’t say, “Class 1 drugs only.” It doesn’t say, “but, if it’s an easy problem with prescription drug management, don’t count prescription drug management.” It says, simply, “prescription drug management.”

Some coders incorrectly insert their own judgment into the determination of whether to count prescription drug management. I don’t know of any official citation to support that. I do know the official citation that doesn’t support that: The Documentation Guidelines themselves.

Remember what Dr. McCoy says, “The bureaucratic mindset is the only constant in the universe.” While we are using these complex guidelines, let’s not add to bureaucratic mindset by developing our own guidelines. Use the ones CMS and the AMA developed.

CMS proposes payment for chronic care management in 2015

In the 2015 Proposed Physician Fee Schedule released on the eve of July 4 (CMS loves holiday releases of rules) CMS states they want to support primary care. One of the ways they are proposing to do this is to add a new benefit: chronic care management (CCM). They are proposing a rate of $41.92 for 20 minutes or more of this non-face-to-face service during a 30-day period.

Here’s how they define it Gxxx1: 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; 20 minutes or more; per 30 days.” (Gxxx1 is a dummy code. CMS will release the HCPCS code in November, when the release the Final Rule.) CMS will not use the CPT codes for complex chronic care coordination services 99487—99489. Those will continue to have a bundled status indicator.
In order to be eligible the patient must have two or more significant chronic problems, expected to last at least 12 months or be life long conditions. They must be the type of condition that poses a real risk to the patient’s health and well being. The practice must implement a care plan that addresses the patient’s conditions and spend 20 minutes during a 30-day period coordinating care and communicating with the patient. The practice must use a certified EHR. In 2015, the version must be certified to at least the 2014 Edition certified criteria. Everyone who has contact with the patient must have access to the electronic record. The EHR must have an electronic care plan accessible to all. The electronic record must include a full list of problems and medications and should facilitate caring for the patient during care transitions. Medication reconciliation is required as part of the service. The patient must have access to the practice 24 hours a day, 7 days a week. One provider must be designated for continuity of care. Care management includes assessment of the patient’s medical, functional and psychosocial needs.
The practice must create a patient-centered care plan, manage care transitions, and coordinate with home and community services. The care plan must be available electronically to all caregivers and available in an electronic or paper copy to the patient.
The practice must inform the patient that they will provide this service and get written consent from the patient to do so. The practice must also inform that patient that they can revoke this consent and stop receiving CCM services at any time. Document these communications in the record, and give the patient a written or electronic copy of the care plan. The co-pay and deductible are not waived for this service, but will be patient due.
CMS is proposing general, not direct, supervision of the clinical staff who perform these services. Nursing staff after hours or during normal business hours may perform these coordination services even if the physician or billing NPP is not in the office
It looks like a lot of work to me for $41.92. If the practice is already providing these services as part of a patient centered medical home, the service will be easier to provide and may not represent significant additional cost. The payment may support the additional infrastructure needed to manage the care of these patients.

Are changes coming to the global period?

CMS released its 2015 Proposed Physician Fee Schedule Rule at 5 pm July 3, 2014. Right before a three day weekend. But, since I’m giving a webinar on the rule July 10, I read away, in between soccer and fireworks. Over the next few weeks, I’ll post summaries of some of the proposals in the rule. On Halloween (CMS loves holidays), when the 2015 Final Rule is released, I’ll add additional posts.

CMS is proposing changes to the definition of the global period, effective in 2017 and 2018. Now, these are proposals and CMS is requesting comments from stakeholders. Nothing in the Proposed Rule is decided on! CMS notes that the payment for 3000 surgical CPT codes includes pre-operative services, intraoperative services and post-operative care. The Office of Inspector General did two reviews, one of Ophthalmology surgical care and one of Orthopedic care. They reviewed the medical records and determined how much post-op care was provided for a sample of these codes. They found that the “value” of the post-op care was less than the value assumed in the surgical care code. Sometimes, the patient receives follow up care elsewhere, and in that case, that physician reports an E/M code. Sometimes, the patient elects not to follow up. The value of the surgical code is built assuming a certain number of follow up visits, and these are not always needed or performed. The value of the codes is assumed to be provided in the office, in a non-facility status. But, some of the services are provided in provider based clinics which have facility status and have lower value. All in all, CMS believes that these global surgical codes may be mis-valued. They are soliciting comments on their proposal to remove post-op care from surgical codes with 10 global days in 2017 and for surgical codes with 90 global days in 2018. It is a proposal and they are asking for our thoughts, opinions and reactions.

It might not be a bad idea. The complaint I hear from most surgeons is about the outliers in the other direction. The post-op patient with multiple co-morbidities who has a non-healing wound and needs more frequent and intense follow up. If there is a mechanism for being paid for those cases, it would be a relief to many surgeons.