What the 2017 Changes to the CCM Regulations Mean to Your ...€¦ · 2015/2016 • Required to obtain written consent from the patient to be enrolled in a CCM program • The consent

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Building Leaders – Transforming Hospitals – Improving Care

What the 2017 Changes to the CCM

Regulations Mean to Your Practice

© HTS3 2017

• Turnaround

Strategy

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Compliance

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Development

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Formerly known as Brim

Healthcare we have a

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delivering superior

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results for our clients.

We believe that the combination of People, Process & Technology transforms healthcare & provides the required

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Our Company

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Our Team Our Mission

Management Placement Consulting Technology

Who We Are

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Faith M Jones, MSN, RN, NEA-BC

Director of Care Coordination and Lean Consulting Faith Jones began her healthcare career in the US Navy over 30 years ago. She

has worked in a variety of roles in clinical practice, education, management,

administration, consulting, and healthcare compliance. Her knowledge and

experience spans various settings from ambulatory to inpatient to post-acute.

In her leadership roles she has been responsible for operational leadership for all

clinical functions including multiple nursing specialties, pharmacy, laboratory,

imaging, nutrition, therapies, as well as administrative functions related to

quality management, case management, medical staff credentialing, staff

education, and corporate compliance. She currently implements care

coordination programs focusing on the Medicare population and teaches care

coordination concepts nationally.

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Instructions for

Today’s Webinar

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• You may type a question in the text box if you have a question during the presentation

• We will try to cover all of your questions –but if we don’t get to them during the webinar we will follow-up with you by e-mail

• You may also send questions after the webinar to Faith Jones (contact information is included at the end of the presentation)

• The webinar will be recorded and the recording will be available on the HealthTechS3 web site

www.healthtechs3.com

HealthTechS3 hopes that the information contained herein will be informative and helpful on industry topics. However, please note that this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. HealthTechS3 does not and shall not have any authority to develop substantive billing or coding policies for any hospital, clinic or their respective personnel, and any such final responsibility remains exclusively with the hospital, clinic or their respective personnel. HealthTechS3 recommends that hospitals, clinics, their respective personnel, and all other third party recipients of this information consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters.

© HTS3 2017 © HTS3 2017

CMS is Committed to

Care Coordination

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Today we are going to talk about:

–What has stayed the same

–What has changed

–What is new

The Agenda

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“Our goal is to recognize the trend

toward practice transformation and

overall improved quality of care, while

preventing unwanted and

unnecessary care”

CMS CFR 11-12-2014

The Goal is the Same

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“We acknowledged that the care coordination included in services such as office visits does not always describe adequately the non-face-to-face care management work involved in primary care and may not reflect all the services and resources required to furnish comprehensive, coordinated care management for certain categories of beneficiaries”

CMS CFR 7-15-2015

Rationale is the Same

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Care Team Utilization is the Same

“…new and evolving care delivery models, which feature an increased role for non-physician practitioners (often as care coordination facilitators or in team-based care) have been shown to improve patient outcomes while reducing costs, both of which are important Department goals as we move further toward quality- and value-based purchasing of health care services in the Medicare program and the health care system as a whole.”

Vol. 80 Wednesday, No. 135 July 15, 2015, P 226

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© HTS3 2017

Elements for CCM are the Same

Practice Eligibility

• Qualified EMR

• Availability of electronic communication with patient

and care giver

• Collaboration and

communication with

community resources &

referrals

• After hours coverage

• Care Plan Access

• Primary Care Provider supervision of clinical staff

Patient Eligibility

• Medicare Patient

• Two or more chronic conditions expected to last at least 12

months or until the death of

the patient

• At significant risk of death,

acute exacerbation,

decompensation, or functional

decline without management

• Patient Consent

• CCM initiated by the primary care provider

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The How has Changed

Practice Eligibility

• Qualified EMR

• After hours coverage

• Availability of electronic

communication with patient

and care giver

Collaboration and

communication with

community resources &

referrals

Care Plan Access

Primary Care Provider supervision of clinical staff

Patient Eligibility

• Medicare Patient

• Two or more chronic conditions expected to last at least 12

months or until the death of

the patient

• At significant risk of death,

acute exacerbation,

decomposition, or functional

decline without management

Patient Consent

CCM initiated by the primary care provider

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© HTS3 2017

Care Plan Access

2015/2016

• The care plan must be

available electronically to all members of the care team

24/7

• Access for urgent chronic

condition needs

2017

• The care plan must be

available in any format to the members of the care team in a

timely manner

• Access for urgent needs

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© HTS3 2017

PCP Supervision of Clinical Staff

2015/2016

• For clinics paid on the PFS,

TCM and CCM are performed by staff under

General Supervision

• For RHCs and FQHCs, TCM

and CCM are performed by

staff under Direct Supervision

2017

• All types of practices can

perform TCM and CCM under General Supervision

• Allows for Third Party assistance

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Collaboration and Communication

2015/2016

• Required to include community resources and other providers in the care of the CCM patient as appropriate

• Ability to communicate electronically with community resources and other providers

• Specifically noted that faxing was not considered electronic

2017

• Required to include community resources and other providers in the care of the CCM patient as appropriate

• Although electronic communication is preferred, faxing is allowable

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CCM Initiation by PCP

2015/2016

• Required PCP to initiate CCM at a face to face comprehensive visit, at the annual wellness visit, or at the Welcome to Medicare Visit.

• The PCP must introduce the CCM program, explain the chronic conditions to the patient, and determine and document the level of decline if left unmanaged.

2017

• Requires the PCP to initiate CCM with the patient but only has to be done on a qualifying face to face visit for “new” patients or patients that they have not seen within the last year for a qualifying visit.

• The PCP must still explain the chronic conditions to the patient, and determine and document the level of decline if left unmanaged even if not seeing the patient in a face to face visit.

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Patient Consent

2015/2016

• Required to obtain written consent from the patient to be enrolled in a CCM program

• The consent form requires a list of elements including a HIPAA statement stating that the patient grants the sharing of info with others involved in their care.

2017

• Required to obtain consent from patient. May obtain consent in writing or verbally.

• If consenting verbally, the provider must go over and document all elements of the program

• When obtaining consent must include all of the elements as required previously except the HIPAA statement

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Additional Payment Elements: –Care Coordination for practices with

Behavior Health Integration

–PCP Involvement in the Care Plan

–Expanding the CCM CPT to a “Family of Codes”

–Use of Telehealth for Advance Care Planning

What’s New?

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© HTS3 2017 © HTS3 2017

• Psychiatric Collaborative Care

Management (CoCM) – “New coding and payment mechanisms

for behavioral health integration (BHI)

services”

– “While there is some overlap between

psychiatric CoCM and CCM services, they

are distinct services”

CoCM and CCM

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“We [CMS] stated that we believed that the resources required to furnish complex chronic care management services to beneficiaries with multiple (that is, two or more) chronic conditions were not adequately reflected in the existing E/M codes. Medical practice and patient complexity required physicians, other practitioners and their clinical staff to spend increasing amounts of time and effort managing the care of comorbid beneficiaries outside of face-to-face E/M visits, for example, complex and multidisciplinary care modalities that involve regular physician development and/or revision of care plans; subsequent report of patient status; review of laboratory and other studies; communication with other health care professionals not employed in the same practice who are involved in the patient’s care; integration of new information into the care plan; and/or adjustments of medical therapy.”

Complex CCM

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CMS-1654-F pg. 280 CFR 11-15-2016

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• CMS conducted practitioner interviews of those who were providing CCM and found that: – “Typically, these practitioners reported

spending between 45 minutes and an hour per month on CCM services for each patient, with times ranging between 20 minutes and several hours per month”

– “absent multiple levels of CCM coding, we do not have comprehensive data on the relative complexity of the CCM services furnished to beneficiaries”

Complex CCM

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CMS-1654-F pg. 283 CFR 11-15-2016

© HTS3 2017

Family of Codes

CCM

99490

• All elements of program are met as previously

discussed

• At least 20 min of clinical

staff time in the month

• Billed only once per

calendar month

• Applies to PFS clinics,

RHCs and FQHCs.

Complex CCM

99487 and 99489

• All elements of program met as previously discussed PLUS

– Moderate or high complexity medical decision making;

• At least 60 min of clinical staff time in the month.

– Use code 99489 for each additional 30 min of clinical staff time in a month

• Billed only once per calendar month

• Only applies to PFS clinics

– RHCs and FQHCs may not bill

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• Additional payment coding for “when the billing practitioner initiating CCM personally performs extensive assessment and care planning outside of the usual effort described by the billed E/M code” – “the practitioner could bill G0506 in addition to

the E/M code for the initiating visit (or in addition to the AWV or IPPE), and in addition to the CCM CPT code 99490 (or proposed 99487 and 99489) if all requirements to bill for CCM services are also met”

– Does not apply to RHCs or FQHCs

Provider Initiation for CCM

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CMS-1654-F pg. 290 CFR 11-15-2016

© HTS3 2017 © HTS3 2017

• The advance care planning CPT codes have been added to the Telehealth List – “99497 (advance care planning including the

explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), or surrogate);

– 99498 (advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (list separately in addition to code for primary procedure))”.

Advance Care Planning

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CMS-1654-F pg. 96 CFR 11-15-2016

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THANK YOU!

Faith M Jones, MSN, RN, NEA-BC

HealthTechS3

[email protected]

Building Leaders – Transforming Hospitals – Improving Care Page 25