Can I get paid to sign the home health certification form?

CMS pays a small fee for the planning, certification, supervision and re-certification of home health services.  Don’t do the work and forget to get paid. Click the link below to watch this brief video about getting paid to sign the home health certification form.

Can I get paid to sign the home health certification form

For more coding resources visit


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.





CMS resources on CCM

Two links I thought you might find helpful.

We appreciate the detail from CMS on chronic care management.

Chronic Care Management: new CPT and CMS benefit code for 2015


In the 2015 Final Physician Fee Schedule released on Halloween (CMS loves holiday releases of rules) CMS continues to state its support for primary care. One of the methods: a new benefit, chronic care management (CCM) for which they are proposing a rate of about $40 for 20 minutes or more of this non-face-to-face service during a calendar month. We knew about this from the proposed rule but were in wait and see mode until the final rule came out.

Here’s a surprise! CMS is going to use a CPT code instead of developing a HCPCS code to describe the service. In the proposed rule they stated their intention of developing a HCPCS code but they’ve changed their minds. This means that practices can learn about this code right in a resource that is sitting on their shelves. I hope everyone reading this has their 2015 CPT code on the desk right now.

The new CPT code is 99490: chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following elements:
• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
• chronic conditions placed the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
• comprehensive Care plan established, implemented, revised, or monitored.

There is an additional editorial note stating “chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately.”

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 conditions that pose 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 a clinical staff member must spend 20 minutes during a calendar coordinating care and communicating with the patient. The practice must use a certified EHR. The physician develops a care plan, and everyone who has contact with the patient must have access to the electronic care plan. A copy of the care plan is provided to the patient, electronically or on paper. 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.

Informed consent is required before starting the service. The practice must inform the patient that they will provide this service and get written consent from the patient to do so and to share information with other providers. 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 $40.00. The practice may only report this service during the month in which the clinical staff has 20 minutes of non-face-to-face time with the patient. 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.

If you have your 2015 copy of the CPT book—and, again, I hope you do– you can read for yourself in more detail what the billing rules are. I am summarizing these but it is no substitute for reading them yourself. First, both CPT and CMS state that clinical staff should be doing the work. Also, a practice may not count any clinical staff time on a day when the physician or qualified healthcare professional (NP/PA) has an evaluation and management service with the patient. However, E/M services may be reported during the same calendar month the chronic care management is provided. There is a list of services in the CPT book that are bundled into chronic care management. These include care plan oversight and transitional care management, amongst other codes. The surgeon may not perform chronic care management during the postop period.

If your practice is already a patient centered medical home or you are already providing case management for a group of chronically ill patients, you are ready to begin performing chronic care management. However, if you are not already providing the services it is unlikely that you will be able to do these starting January 1. It requires an infrastructure within the practice to provide the services. Also, you will need to have an evaluation and management service with the patient to explain the service, sign the informed consent, and develop the care plan. This calls for gradually rolling out chronic care management services not immediately reporting them on all patients who will be eligible. Remember this is not a per member per month benefit– just because you provide the service one month does not mean you can provide the service the next month. The clinical staff must spend at least 20 minutes providing these coordination and care management services in order to report them. Most practices don’t have a template or form setup for this. Groups will need to think about how and where this information is being documented before rushing to bill for this service.

By Narath Carlisle, MD, MPH

Skype ≠ Telemedicine

I got a call from a vendor trying to develop a video conferencing product for a physician to use to talk to a patient who is at home. He said “I’m having trouble finding codes for telemedicine that the doctor can use.” Aren’t we all.

Talking to your patient using a secure video connection doesn’t meet the criteria for telehealth as developed by CMS. There are no current CPT codes that describe that situation. There is no way to report it to the insurance company and be reimbursed for the service. There are CPT codes for non-face-to-face services such as phone calls and on-line medical evaluations, but they don’t describe a video discussion with a patient and have a status indicator of non-covered. (Insurance won’t pay, bill the patient). Interprofessional telephone/internet consultation codes describe physician-to-physician consults and have a status indicator of bundled. (No one will pay.)

What about CMS’s telehealth benefit? Telehealth is a covered service between a patient in an originating setting that is in a Health Professional Shortage Area or in a county outside of a Metropolitan Statistical Area. The originating site is a physician office, hospital, critical access hospital, rural health clinic, federally qualified health center, skilled nursing facility or community mental health center. Home is not one of the locations. The patient is located in one of these settings and their provider requests that a distant health professional assess and treat the patient through video-conferencing. There are specific CPT codes that may be reported in these instances. Telehealth as currently defined does not mean that a physician or healthcare professional uses a video-conference to treat their own patient.

Now, you’ll tell me we are moving from fee-for-service medicine into caring for our patients in a way that doesn’t require them to drive to our offices. We have mobile apps for monitoring their well being, and our goal is to keep them healthy and not consuming healthcare resources. (That’s a euphemism for driving up costs we’re at risk for.) But, most of us aren’t there yet. Most of our revenue comes from fee-for-service and there is no CPT or HCPCS code that currently describes a physician using video-conferencing to talk with their patient.

You can download CMS’s telehealth fact sheet



The ICD-10 Emperor Has no Clothes

Previously published on

The howling about the delay of ICD-10 was loud and fierce. It seems the quality of healthcare in the United States depends on our ability to use 68,000 diagnosis codes. The rest of the world has switched to ICD-10, and we alone insist on using an outdated coding system. Here’s a secret. The World Health Organization’s version of ICD-10 has about 16,000 codes, equivalent to ICD-9-CM. The rest of the world is not using ICD-10-Clinical Modification set, which has 68,000 codes. Only we, in the US, are considering that. The Canadian version of ICD-10 has about 16,000 codes, but the physicians do not use those codes for billing and reimbursement. They use a more limited code set of about 600 three-digit codes. Let me repeat this: the WHO version of ICD-10 that the rest of the world uses: about 16,000 codes. Our version, developed jointly by the CDC and the American Hospital Association has 68,000 codes.

 ICD-10-CM is going is going to add significant cost and complexity to physician practices without any benefit to the patient or physician. Perhaps facilities or payers need this level of detail, but we on the medical practice side do not. Selecting an ICD-10 code in an electronic health record will add 1-3 minutes to each patient encounter. Is that a reasonable use of physician time? If your mother or child is in the exam room, wouldn’t you prefer that the doctor spent that time with your family member, or you?

 For years, I listened to the experts say that we needed greater granularity and detail in our diagnosis coding. The transition from ICD-9-CM to ICD-10-CM increases the number of diagnosis codes from about 14,000 to 68,000. That is significant additional granularity. But, when I studied ICD-10-CM in order to teach it to physicians and coders, I realized the ICD-10 Emperor has no clothes.

 My objections to ICD-10-CM are that it includes needless specificity, absurd adherence to taxonomy, unnecessary detail about injuries and insufficient additional information about chronic illnesses to justify its use.

 In ICD-9, there are about a dozen codes for acute or chronic conjunctivitis. There are about 50 in ICD-10. Here are four: unspecified chronic conjunctivitis, right eye, unspecified chronic conjunctivitis, left eye, unspecified chronic conjunctivitis bilateral eyes, unspecified chronic conjunctivitis, unspecified eye.

 Coding for gout explodes from about a dozen codes in ICD-9 to over 150 codes for gout in ICD-10-CM, differentiating chronic gout, lead induced chronic gout, drug induced chronic gout, chronic gout due to renal failure, other secondary chronic gout, acute idiopathic gout, acute lead induced gout, drug induced chronic gout, chronic gout due to renal impairment, and other secondary chronic gout. Each is reported by joint and acute gout by with or without tophus. Idiopathic gout right knee, idiopathic gout left knee, idiopathic gout unspecified knee. Or, chronic gout, unspecified. You don’t believe me do you? Get out your ICD-10-CM book and compare the codes using the search function on the WHO website for ICD-10.

 Of the 68,000 codes over half are for injuries and accidents. Is it a laceration with or without a foreign body, which side, initial or subsequent encounter? Is the fracture at the upper or lower end of the ulna? What type of fracture is it? The mainstream media focused on the external cause codes “struck by a parrot.” But, these external cause codes are the least of our worries as we attempt to use ICD-10-CM in medical practices. And, I assure you, “struck by a parrot” is not in the WHO ICD-10 code set.

 Now I’m sure that in response to this post you will show me the chronic care codes that have increased specificity and provide additional information for physicians health systems and payers. I know they exist. Great, let’s use a version that includes those codes without all of the other detail.

 If Stark was the full employment act for lawyers, and HIPAA was the full employment act for consultants, then ICD-10 is the full employment act for coders. Much of the outrage against ICD-10 came from my fellow coders and consultants. I am sure that some of them have a deep-seated belief that ICD-10 is better. And, coding is the job coders have selected to do, and coding in ICD-10-CM is a fun, interesting activity for coders. Not so much for physicians.

 In the 1986 movie, “Star Trek IV the Voyage Home” Dr. McCoy says, “the bureaucratic mind set is the only constant in the universe.” You remember the scene don’t you? Our heroes are in a shuttle…. well, maybe you don’t remember the scene. Dr. McCoy wasn’t talking about ICD-10-CM, but we can imagine his reaction to it. “Dammit Jim, I’m a doctor not a coder.” But, in medical practices today, the physician typically selects the CPT code and the diagnosis codes that were the reason to provide the service and the diagnosis code that is the indication to order tests. ICD-10-CM will do little more than increase the bureaucratic side of physicians’ lives at the expense of their being doctors.




Tell me something I don’t know: confusion in reporting Psychiatry services

CMS recently released a MedLearn Matters article about coding for psychotherapy and evaluation and management (E/M) services on the same day. This article reported that the comprehensive error rate testing contractor (CERT) had found a high error rate when E/M services and psychotherapy are reported together. Tell me something I don’t know.

 In 2012 physicians, nurse practitioners, physician assistants and clinical nurse specialists working in psychiatry reported medication management with code 90862. That code was deleted in 2013. Medical practitioners working in psychiatry who performed medication management were instructed to report the service with E/M codes. If psychotherapy was provided there were new add-on codes for psychotherapy reported with medical evaluation services. The CPT book instructed clinicians not to use the time spent for the E/M service to determine the level of service for psychotherapy. While psychotherapy codes are time-based codes, E/M services may be reported either based on time (unless provided on the same day as psychotherapy) or based on the three key components of history, exam, and medical decision-making. It was all very confusing to medical clinicians working at psychiatry.

 The MedLearn Matters article tries to clarify this. “The main error that CERT has identified with the revised psychiatry and psychotherapy codes is not clearly documenting the amount of time spent only on psychotherapy services. The correct E&M code selection must be based on the elements of the history and exam and medical decision making required by the complexity/intensity of the patient’s condition. The psychotherapy code is chosen on the basis of the time spent providing psychotherapy.” That is, select the E/M service based on the history, exam, and medical decision-making documented and add a note “After the E/M service, I spent XX minutes in psychotherapy with the patient.” Describe the psychotherapy.   The article further stated that it needed to be clear that the time spent in psychotherapy did not include the time of the E/M service.“Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.”

Clinicians tell me that this is a false delineation, and that there is no easy way to mark when the E/M service stopped and the psychotherapy started. But, these are the coding rules that we have in 2014. What is a medical clinician working in psychiatry to do?

Providing medication management or medical evaluation only: if this is the only service provided a clinician may use time or the three key components to select the code. If psychotherapy is not done on the same day, and the visit is dominated by counseling, a clinician may use time to select the code. The CPT describes counseling as dominating the visit when over 50% of the time of the total visit time is composed of discussion of the diagnosis, prognosis, risks and benefits, importance of compliance, and patient or family education. In that case, document the total time and that more than 50% of the time was spent in counseling. “I spent 20 minutes with the patient over half of the discussing the side effects of medication and the other issues above.”

Only psychotherapy is provided: if only psychotherapy is provided and there is no medical E/M, use the psychotherapy standalone codes based on time. These codes are hurt 90832, 90834, and 90837. Document time in the record and describe the psychotherapy that was performed.

When both an E/M services (such as medication management) and psychotherapy are provided on the same calendar date: in this case report both an E/M service and an add on psychotherapy code. Select the level of service based on the history, exam and medical decision making. Then, document the time spent in psychotherapy not including in it the time it took to provide the E/M service.. I suggest documenting the patient’s subjective report, the mental status exam and the assessment in the plan. Then note “after the E/M service was performed I also provided XX minutes of psychotherapy.” Describe the nature of the psychotherapy. Do not document the total time of the visit because that includes both the E/M service and the psychotherapy.

Although most clinicians don’t want to read the CPT book, the section about psychiatry codes includes important editorial comments and instructions for use of the codes. Because there was such a major change in 2013, and Medicare has identified a high error rate for these services it is important for someone in the office to review this section of the book. It will only take 15 or 20 minutes to read through the editorial comments in the psychiatry section and the reward will be an increased understanding and higher coding accuracy.