Written by Brooke Haycraft, CEMC, CFPC, CPC-H, CPC
On October 31, 2014, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Physician Fee Schedule (MPFS) updates for the 2015 implementation. Below are highlights of updates and deeper insights on what changes/updates/policy adjustments providers can expect in 2015.
Chronic Care Management
Primary care providers will now have the opportunity to bill and be reimbursed for chronic care management of patients who meet the appropriate billing guidelines further defined by CMS. CMS has established a reimbursement rate of roughly $40 for non-face-to-face chronic care management (CCM) and can be billed up to once a month for patients who meet policy standards.
Current Procedure Terminology (CPT) has created a new code for 2015 in the Evaluation and Management section for CCM. CPT code 99490, is defined by CPT as chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or at least until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.
CCM services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.
There are several requirements that providers must meet when providing CCM services according to CMS:
- Patient must have 24/7 access to their provider; this will allow patient’s acute chronic care needs to be addressed at any time. The patient would be given a means to contact the practice clinicians in a timely manner. Members of the healthcare team must have access to the patient’s electronic medical record, even after posted office hours.
- Provide continuity of care with a designated clinician or member of the care team with whom the patient would be able to obtain routine appointments.
- Provider must conduct an assessment of the patient’s medical, functional, and psychosocial needs.
- Healthcare provider must utilize system-based approaches to ensure timely receipt of all recommended preventive care services.
- Provider must continue to monitor medications and usage with review of potential interactions.
- Provide guidance of patient’s self-management of medications.
- Develop an extensive, patient-centered care plan written in consultation with the patient and other key contributors who are treating the patient, based on physical, mental, cognitive, psychosocial, functional and environmental assessment. This also includes reassessment and an inventory of resources and supports, assuring that the care provided is compliant with the patient’s wishes and values.
- Manage care transitions within health care, including referrals to other specialists, visits that follow an emergency department visit, discharge from hospitals, and skilled nursing facilities.
- Coordinate with home- and community-based clinical services.
- Provide opportunities for the patient to communicate with the clinician, to include not only the telephone but also secure messaging, Internet communication or other same-time consultation methods.
Telehealth Services
CMS is expanding the telehealth benefit available to Medicare beneficiaries to include the following services—
- Psychotherapy services;
- Psychoanalysis (90845)
- Family psychotherapy without patient present (90846)
- Family Psychotherapy with patient present (90847)
- Prolonged services in the office (CPT codes 99354 & 99355)
- Annual wellness visits (HCPCS codes G0438 & G0239)
Of note, CMS did not eliminate the original telehealth billing requirements initially implemented—
- Patients must reside in a rural, healthcare professional shortage area.
- Health care professional is licensed in the state where the telehealth service is being delivered.
- Telehealth services are delivered through an interactive telecommunications system.
Value Based Payment Modifier (VBPM) & Physician Quality Reporting System (PQRS)
CMS has developed several quality initiatives that provide information on the quality of care across diverse healthcare settings, including home health agencies, hospitals, skilled nursing facilities, and dialysis facilities for end-stage renal disease. CMS is ultimately aiming to support new payment systems that provide more financial resources to provide improved quality care, rather than simply paying based on the volume of services.
The VBPM allows for differential payments to physicians or groups of physicians under the MPFS based upon the quality of care furnished compared to cost during a performance period. VBPM is also intended to provide comparative performance information to providers. Payment increases for providers that administer high-quality healthcare to their patients while reducing the actual costs of services provided.
The 2015 MPFS final rule states that, beginning in 2017, solo physicians, physician groups with two or more eligible professionals (EPs), and providers who are part of Medicare Accountable Care Organizations (ACOs) will all be subject to the VBPM program. As this program has previously been subjected to a two-year delay, the bonuses and penalties assessed in 2017 will be based on quality and cost data collected through the PQRS in 2015.
PQRS (initially referred to as Physician Quality Reporting Initiative (PQRI)) is a, ‘pay-for-reporting, not pay-for-performance’ reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality measures for Medicare beneficiaries by EPs. PQRS, in turn, then provides an incentive payment to practices with EPs.
Beginning in 2015, CMS will require that EPs report on at least nine quality measures and report each measure for at least 50% of eligible Medicare beneficiaries to avoid a 2% payment adjustment penalty. PQRS will apply a payment adjustment to EPs who do not satisfactorily report data on quality measures for covered professional services.
The VBPM will be tied to an EPs successful participation in PQRS, putting EPs at risk for an adjustment of -6 percent for failure to satisfactorily participate in PQRS.
Global Surgery—Elimination of 10 and 90 global surgical packages
CMS will be eliminating 10 and 90-day global surgery packages and transitioning to 0-day global surgery codes. 10-day global codes will transition starting in 2017 and 90-day global codes will transition in 2018.
Providers are currently reimbursed a single global fee for 10 to 90 surgical packages. The global surgical package consists of the surgical procedure as well as the pre- and post-surgery visits. Starting in 2017, however, medically necessary visits pertaining to the surgical procedure will be separately payable during the pre- and post-operative periods of the procedure performed.
Why did CMS decide to eliminate global dates? According to CMS, “The typical number and level of post-operative visits during global periods varies greatly across practitioners and beneficiaries,” which, in turn, led CMS to come to the conclusion that, “continued valuation and payment of these face-to-face services as a multi-day package may skew relativity and create unwarranted payment disparities.” CMS also stated that bundling of services into the 10- and 90-day global periods may result in inaccurate payments due to the following factors:
- Payment rates for the global surgery packages are not updated regularly based on any reporting of the actual costs of patient care.
- The relationship between the work RVUs for the 10- and 90-day global codes and the number of included post-operative visits in the existing values is not always clear.
- The 10- and 90-day global periods reflect a long-established but no longer exclusive model of post-operative care that assumes the same practitioner who furnishes the procedure typically furnishes the follow-up visits related to that procedure.
For a complete update of the 2015 Medicare Physician Fee Schedule final rule, please refer below to the following link;
http://www.ofr.gov/OFRUpload/OFRData/2014-26183_PI.pdf