Performing services that increase primary care revenue

Article posted on April 24, 2016

CMS states it wants to increase pay to primary care physicians. And while we might quarrel with their strategies or with the speed of achieving the goal, few would quarrel with the goal itself. In recent years, CMS has developed HCPCS codes and adopted CPT codes, some limited to primary care and some not specialty restricted but all likely to be reported by primary care practices. Meanwhile, although payment systems are moving to outcome and value measures, the revenue for most primary care practices continues to be fee-for-serviced based, and alternate payment models (APM) are built on top of fee-for-service.

Some of the new services defined by CPT HCPCS codes haven’t pleased primary care physicians, either because of the definition of the services or the payment for them. Working with and listening to primary care physicians, I think that some of these services can be embraced and some should be ignored, for the time being. I’m an advocate of implementing Medicare Wellness Visits and transitional care management services into primary care and setting aside chronic care management for most practices. Advance care planning will be relevant in selected practices, but not all. And many other prevention services just don’t pay enough.

There can be significant variation in work RVUs per encounter (or revenue per encounter) within a group. I report on this in an upcoming article in Family Practice Management. When I look at this variance, some of it comes from differences in level of service reporting, but more is from the use of wellness visits and transitional care management.

Thumbs up to wellness visits and problem visits at the same encounter

Some physicians objected to the definition of the Welcome to Medicare and initial annual and subsequent annual wellness visits (AWV) because there was no required physical exam. These visits don’t prohibit doing an exam. The Welcome to Medicare and initial wellness visit have high work RVUs and payment. Medicare allows a physician to bill a problem oriented visit on the same day, as long as the documentation for the wellness visit isn’t used to select the level of problem oriented visit. The wellness visits don’t require HPI, ROS, exam or assessment and plan of a problem. When I review documentation, I find that many of these visits document the requirements of the wellness visit and the key components of a problem-oriented visit. In practices that have implemented the wellness visits successfully, staff members collect and record the data for the wellness visit, and the physician or non-physician practitioner (NPP) documents the personalized prevention plan and, if relevant, the problem-oriented visit. Of course, both must be documented—describe the status of the patient’s chronic diseases in the HPI, do an exam and note the assessment and treatment at the end of the note. Reporting wellness visits and when relevant, wellness visits and problem-oriented visits on the same day is good for the patient and good for the practice.

Thumbs up to transitional care management (TCM)

Primary care practices are already managing the transition for hospitalized patients to home, and getting paid only for the office visit. TCM allows the group to be paid for the work the physician, NPP and staff are already doing.   It requires a phone call to the patient in two business days, a visit in 7 or 14 days (depending on the code), reviewing the discharge summary and medication reconciliation. It is not for every discharge. It is for patients who need additional non-face-to-face support by the medical and clinical staff in the transition to home. It has high work RVUs and reimbursement. CMS changed the rules January 1, 2016 allowing the visit to be billed on the day of the E/M office visit, rather than waiting 30 days from the date of discharge. This is a definite yes: get paid for the work the practice is now doing for free.

Thumbs down to chronic care management (CCM)

CMS states it does not have statutory authority to provide a per member per month benefit for managing patients with chronic diseases. Instead, they can pay monthly for 20 minutes of clinical staff time for patients with two or more significant chronic illnesses. Staff must count minutes, and only report the service in months they have 20 minutes. A care plan must be developed at a “comprehensive” E/M service, the patient must sign informed consent, and other physicians who care for the patient must have electronic access to the care plan, not via fax. There are practices that can do this, but not most. All for about $40/month. My advice: wait on CCM unless you have a very sophisticated case management program in place.

Thumbs up, equivocally, to advance care planning (ACP)

Beginning in 2016, physicians and NPPs can be paid for discussion of end of life issues with patients and/or family members. The Medicare payment is about $86 for a discussion of 30 minutes. Since coding is through the looking glass, a clinician must meet over half of 30 minutes, 16 minutes, to bill for the service. That’s a long time for a service in the office. It can be billed with an office visit, but the time of the office visit and the time of the ACP can’t be double counted. When I think it will be useful is for a patient’s family member who wants to come in to discuss a change in the patient’s condition and long term plans. Or, for a physician and family member of a hospitalized patient. After rounding in the morning, a physician could have a discussion with a family member in making end of life decisions. This isn’t a code that can be used every day of a hospitalization, but when the patient’s condition changes and warrants the discussion. When it is done on the same day a wellness visit and submitted with modifier 33, there is no co-pay or deductible. But, it might be difficult to perform on the day of a wellness visit because the wellness visit is time consuming on its own.

Thumbs down to HCPCS codes with low RVUs

CMS is required to cover any service that the USPSTF gives an A or B rating. But, that doesn’t mean they have to pay adequately for the service. If you download the CMS preventive medicine chart (here you’ll see some of these services. G0442 screening for alcohol misuse, 15 minutes. Even using the CPT rule of meeting over half of the threshold, does alcohol screening take 8 minutes? And the payment is under $20. Annual depression screening is reported with code G0444, also a 15 minute code. The patient filling out the PHQ9 doesn’t take 8 or 15 minutes, and it also has a payment rate of under $20. 15 minutes of behavioral counseling for obesity, G0447, has a slightly higher reimbursement rate. Of course, practices will screen for alcohol misuse and depression, but the HCPCS G-codes will probably not describe the service that was performed.

If your primary care practice hasn’t adopted the wellness visits and TCM, I urge you to take a second look at implementing them. Both AAFP and ACP have resources that will help.

CMS Updates, TCM, CCM and ACP

At CMS’s Open Door Forum on April 13, 2016 CMS noted there were updates to the Frequently Asked Questions documents for Transitional Care Management, Chronic Care Management and Advance Care Planning. The CMS staff discussed these and answered questions about them. I’ve written about all three topics on this blog, and you can read about them in more detail. At the end of this article, I’ve attached the links to the CMS documents. I strongly recommend that you download and read these three resources. Here are some highlights.

TCM: CMS affirmed that a practice may bill for TCM on the day of the face-to-face visit, without waiting for the 30 day period to pass. Use the place of service in which the visit took place. The biggest change? CMS is following CPT rules about attempting (but failing) to have phone or other direct contact in two business days from the date of discharge. “If two or more separate attempts are made in a timely manner and documented in the medical record, but are unsuccessful, and if all other TCM criteria are met, the service may be reported. We emphasize, however, that we expect attempts to communicate to continue until they are successful, and TCM cannot be billed if the face-to-face visit is not furnished within the required timeframe.”

TCM and CCM in the same month: It is possible to report TCM services in the same month as CCM if and only if a) the 30 day TCM period ends before the end of the month, and b) 20 minutes of CCM time is provided between the end of the TCM service and the end of the calendar month.

CCM: In order to report CCM, individuals who are providing the 20 minutes CCM time need access to the patient’s medical record. However, CMS has clarified in this new document that the access must be to the care plan, not the entire record. “This article alerts providers that the Centers for Medicare & Medicaid Services (CMS) revised the Medicare Learning Network® Fact Sheet on CCM services (ICN 909188, released in March 2015) to clarify Medicare’s requirement for 24/7 access by individuals furnishing CCM services to the electronic care plan rather than the entire medical record.”

CMS continues to defer to CPT in the definition of clinical staff, and to refer to the Medicare Benefit Policy Manual for incident to guidance. Supervision of staff for CCM and TCM is general, not direct. That is, the physician or other billing provider does not have to be in the suite of offices when the service is performed.

A practice may bill for CCM on the date the twenty minutes in the month is achieved. The practice doesn’t have to wait until the end of the month to report CCM.

Advance Care Planning: 99497 and 99498 are time based codes, and CMS has affirmed that they follow CPT time rules. That is, in order to bill the code you need to have reached over half of the time listed in the code. To report 99497, the provider must have spent 16 minutes with the patient; to report 99498 the provider must have spent 46 minutes. CMS affirmed that this can be done by as a team service, if the physician or non-physician practitioner start the discussion with the patient. This does not mean medical assistant! But, a social worker or someone with palliative care experience could work with the patient in addition to the physician. CMS is clear that this is a provider service.

If you are performing these services, or thinking of performing them in your office, download and read the articles. They consist of frequently asked questions Medicare has received about these services. If you have a question, there is a good chance it is asked and answered in these three documents.