Category: Practice Management

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HCCIntel Practice Management Tip of the Month Training & Education

Evaluating Your Staffing Model

Home-based primary care staff

Home-based primary care staff

Staffing costs are responsible for the largest share of a house call program’s expenses, so it is essential that staffing is appropriate to meet the needs of patients in the service area without sacrificing productivity. To enhance sustainability, a house call program should be evaluating its staffing on a regular basis. Some questions to consider:

  • Are schedules full? Are patients able to schedule timely appointments?
  • Are patients experiencing long hold times or abandoned phone calls?
  • What is the average wait time for a new patient?
  • Does schedule allow for prompt post-acute follow up?
  • Are patients able to obtain timely RX refills, prior authorizations, and referrals or do you receive complaints often?
  • Are all team members working to the top of their scope or burdened with administrative tasks?
  • Are in-basket (EHR) or incoming messages addressed or reviewed by end of the day or do several remain unopened and/or unaddressed for the next day?
  • Are lab and diagnostic test results reviewed and responses provided to patients in a timely manner?

Also, don’t forget that your practice can leverage a variety of data and metrics to evaluate if the staffing is appropriate. For example:

  • Incoming call volume
  • Average messages per day addressed by clinical staff and provider team
  • Productivity per providers and practice as a whole
  • Average increase of new referrals and referral source
  • Days from referral to first visit and days to transitional care visits from discharge
  • Annual patient, provider, and employee satisfaction surveys

Remember, there is no “one size fits all” staffing model. Consider your program’s mission, business plan, and patient population to determine what’s best for your practice, and then capture and regularly review meaningful practice metrics. By keeping a regular focus on these critical data, you will be able to ensure your program’s staffing is aligned with productivity targets and is appropriate to meet needs within the service area.

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HCCIntel Practice Management Tip of the Month Training Training & Education

How to Confidently Get Reimbursed for Prolonged Services (Non-Face-to-Face)

Medical Billing and Coding

Since January 1, 2017, the Centers for Medicare & Medicaid Services (CMS) has authorized payment for CPT codes 99358 – 99359 for prolonged services non-face-to-face (F2F). When used correctly, this is a significant reimbursement opportunity for Home-Based Primary Care (HBPC) providers.

The CMS national payment rate for 99358 is $113.52 (the rate for 99359 is $54.78) with a Relative Value Unit (wRVU) of 2.10. This provides payment for the extensive medical management that occurs outside of the F2F visit. Although the use of these codes offers financial benefits, many practices continue to have concerns and/or questions regarding the services, leading to these codes being underutilized.

To help you receive the appropriate amount of reimbursement for the work your providers are doing under these codes, review the below requirements and apply them when appropriate:

  • The provider’s work is payable for both the office and outpatient setting (e.g., home or domiciliary visits, hospital, and nursing facility).
  • Time guidelines:
    • The billing physician or other qualified health care professional must spend a minimum of 31 minutes beyond the typical F2F time associated with the service as time directly related to an Evaluation and Management (E/M) F2F visit.
    • This time must be beyond the usual service time a provider would spend with the patient.
    • The provider must document why the service went above the normal time and effort.
    • The non-face-to-face time may occur on the same or a different date (i.e., before or after the visit) as the E/M F2F visit, if the documentation references the primary service it’s related to.
    • The exact amount of time spent must be documented in the medical record; the time does not need to be continuous (e.g., 20 mins in the AM and 15 mins in the PM), however, it must occur on the same calendar date.
    • The total time cannot be a compilation of times added together from various calendar days.
    • The service provided cannot be reported for time spent in non-face-to-face care described by more specific codes having no upper time limit within the CPT code set.
    • CMS notes that, while the typical CPT threshold times are not required for billing prolonged services, it is expected that only time spent in excess of these times is to be reported under CPT codes 99358-99359.
    • Per the CMS Claims Processing Manual, start and stop times are required for documented time (Page 83 of the manual: The start and end times of the visit shall be documented in the medical record along with the date of service).

In summary, your documentation should include start and stop times that show a minimum of 31 minutes spent on time directly related to an E/M visit. If the time occurred on a different date than the visit, you must reference the date of the F2F service and include a brief description of how that time was spent (e.g., nature or topic of what was reviewed or discussed).

In addition, CPT codes 99358-99359 cannot be reported during the same service period as the following due to similarity in service. As of 2020, however, prolonged services will be unbundled with transitional care management services, meaning they can be reported within the same calendar month:

  • Chronic Care Management (CCM)
  • Transitional Care Management (TCM)
  • Care Plan Oversight (CPO)
  • Anticoagulation Management
  • Medical Team Conferences
  • Online Medical Evaluations

For additional reference, the National Government Services (NGS) offers the following examples of appropriate uses of CPT codes 99358-99359:

  • Extensive medical record review directly related to an F2F encounter
  • Extensive telephone time with the patient and/or family that directly relates to an E/M encounter
  • Family/caregiver meeting, even without patient involvement but directly related to an F2F encounter

While these guidelines may seem challenging, you can tackle them by creating a Macro within your Electronic Health Record (EHR) that your providers can use for documentation purposes. In addition, you can create a back-end charge review rule to ensure the work does not get billed out during the same calendar month as other bundled services.

The time you invest in understanding these guidelines will assist in exponentially growing financial benefits for your practice.

Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9905.pdf

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CMS Announces Request for Applications for Primary Care First Model Options

CMS Request For Applications

CMS Request For Applications

CMS Announces Request for Applications for Primary Care First Model Options

(Highlights for Consideration included below)

CMS released the Request for Applications (RFA) for the Primary Care First (PCF) and Seriously Ill Population (SIP) models last Thursday, October 24. The practice application period also started that day while the deadline to apply via the live portal is January 22, 2020.

The model will now begin in January 2021 (a delay of one year from the originally anticipated start date). CMS will select practices and payers during Winter/Spring 2020 and will onboard participating practices and payer partners to the model from July to December 2020.

Following are important highlights of the new program for practices to consider:

Fees and Measurements

  • Under PCF General, the primary care flat visit fee will be reduced to $40.82.
  • HCC Risk Group 4 will be the highest-level risk group with a payment of $175 Per Beneficiary Per Month (PBPM).
  • Practice risk groups 3 and 4 will not use the acute hospitalization performance measure; instead, performance for these groups will be measured on the Advance Care Plan and Total Per Capita Cost (TPCC).

SIP

  • SIP practices are expected to have an 8-month management and transition period for stabilization of their patients and then to transition them back to another primary care setting or practice.
    • This is known as the average length of attribution (LOA).
    • If the 8-month term is exceeded, a $50 PBPM reduction will apply to the monthly SIP payment through a quality adjustment.
  • SIP patients will require a face-to-face visit once every 60 days for them to remain attributed to the practice.
  • SIP payment redesign now states that after a practice conducts its initial face-to-face visit with the SIP patient, CMS will make a one-time payment of $325. With PCF, beginning the month following the initial visit, the practice will receive a $275 PBPM minus a $50 quality withhold that can be earned back with a potential quality bonus at the end of the first performance year.
  • SIP practices must describe the service area(s) in which they are interested in participating using zip codes and must define the maximum number of SIP patients the practice has the capacity and capability to manage.

Participation and Eligibility

  • Practices participating in the Independence at Home (IAH) Demonstration are eligible to participate even if it is not offered in the region(s) of the IAH practice.
  • Practices participating in the Comprehensive Primary Care Plus (CPC+) model cannot participate in 2021, however, they can participate in 2022.
  • Concierge practices, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are not eligible to participate.
  • Eligible practitioners are those practicing in internal medicine, general medicine, geriatric medicine, family medicine and/or hospice and palliative medicine.

Home Centered Care Institute Support

If you have questions about these changes or other home-based primary care questions, you can contact our HCCIntelligence™ Resource Center Hotline at 630-283-9222, 9:00am to 5:00pm (Central Time) Monday through Friday – or email us at [email protected]. The hotline and additional offerings in the Resource Center, including monthly webinars, virtual office hours, and tools and tips sheets are available at no charge due in part to a grant from The John A. Hartford Foundation.

 

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HCCIntel Practice Management Tip of the Month

Chronic Care Management: One Way to Maximize Fee-for-Service Reimbursement

Nurse checking patient's blood pressure.

Would you like to maximize your reimbursements by up to $42 dollars per patient per month for the care being provided? Chronic Care Management (CCM) involves much of what you may already be doing to provide high-quality care for your patients: maintaining a comprehensive electronic care plan, managing transitions, and coordinating care with other professionals within and/or outside of your practice. The good news is that with a basic understanding of Chronic Care Management (CCM) documentation and billing, along with an effective workflow process, you can be fairly paid for providing these valuable services!

In 2015, CCM became separately payable by Medicare; however, it is still underutilized by many providers due to concerns about the documentation requirements or simply because providers don’t understand how this could easily become part of their practice’s workflow.

One concern has been that although many Electronic Health Record (EHR)  systems allow providers to turn on a CCM module for time tracking and other features, it is typically an extra expense to the practice. Many providers find that just by enhancing their knowledge of CCM requirements and by implementing some standardized processes, a CCM module isn’t always needed.

Let’s start with the basics of what qualifies a patient for CCM:

  • Two or more chronic conditions, which are expected to last at least 12 months, or until the death of the patient.
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
  • Comprehensive care plan established, implemented, revised, or monitored.

The medically complex and homebound will all qualify for these services, and home-based primary care (HBPC) practices provide extensive care coordination and management services to their patients. It is pretty typical for providers and clinical staff to spend at least 20 minutes per calendar month to manage their patients’ medical and psychosocial needs.  So why not be reimbursed $42.84 (2019 CMS National Payment Amount) per patient per month? Only 20 minutes of combined clinical staff and providers’ time per calendar month is required to bill for CPT 99490 Chronic Care Management.

If your physicians or other qualified health care professionals (Nurse Practitioners, Physicians Assistants, Certified Nurse Midwives, and Clinical Nurse Specialists) are personally spending a complete 30 minutes within a calendar month addressing the medical and care coordination needs of their complex patients, then you can bill CPT 99491 which pays $83.97 (CMS National Payment Rate).

One potential barrier or source of confusion practices may feel limits their ability to provide CCM services to their patients is how to develop the CCM Comprehensive Care Plan that must be created, monitored, implemented, and provided to patient’s and/or caregivers receiving CCM services. Don’t let this stop you; consider if you have a nurse or other clinical staff that could be designated to support CCM and assist the providers in creating these care plans for patients. Below is an example that contains the care plan fields, which meet CMS requirements.

  • Problem List
  • Expected outcome or prognosis
  • Patient Goals of Care
  • Treatment Plan for each Chronic Condition
  • Symptom Management Plan/Education Resources Provided
  • Care Team (Include roles & responsibilities)
  • Medication List (Mark as reviewed/reconciliation last completed date)
  • Community and Social Services Involved in Care (include role and frequency of interventions)
  • Care Plan Review Date

What other elements are required when providing CCM services to your patients?

  • You must obtain and document either verbal or written consent for the patient to receive CCM services, and only one billing practitioner may provide and report CCM services per beneficiary.
  • Structured Recording of Patient Health Information: Practice utilizes certified EHR technology.
  • Access to Care & Care Continuity: Enable 24/7 access to provider team and other clinical staff with a means for after-hours coverage, designated relationship with a member of the care team, and provide enhanced communication opportunities.
  • Comprehensive Care Management: Systematic assessment/monitoring of all medical, functional, and psychosocial needs, medication reconciliation with review of adherence, potential interactions, and self-management, coordinate home and community-based services.
  • Transitional Care Management: Manage transitions as part of CCM.

For further explanation of the requirements in the CCM Comprehensive Care Plan refer to the following HCCI resource, CCM Care Plan Requirements.

Don’t let the list intimidate you! If you are currently providing longitudinal home-based primary care to your patients, chances are, you are already meeting the requirements but just not billing for it.  This means you could be leaving a significant amount of revenue on the table. To put this in perspective, let’s say you billed 300 traditional CCM charges within a six month period. That’s an extra $12,852 in revenue.

In today’s Fee-for-Service model, you must take advantage of all possible billing opportunities to be sustainable and properly reimbursed for the quality, compassionate care your team is already providing.

 

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HCCIntel Practice Management Tip of the Month Training

Geographic Scheduling: Impact on Home-Based Primary Care Productivity

Geographic scheduling

Geographic scheduling

One of the unique challenges home-based primary care practices face is determining an effective geographic scheduling and route planning process.  The ability to automate and/or optimize routing of patient visits is key to minimizing travel time for providers, boosting productivity and increasing face-to-face time with patients. Dedicating the time and thought into operationalizing the process of geographic scheduling will increase productivity, boost provider morale, and improve bottom line.

Some tips to remember when determining your scheduling outline and process:

  • Define provider scheduling zones utilizing zip codes and/or service areas within proximity.
  • Implement the use of Bing Maps and Google Maps can assist with defining appropriate zones and daily routes for providers.
  • Utilize mapping/scheduling software such as CareLink and RoadWarrior to create reliable multi-destination routes.
  • For smaller practices on a budget, the use of an Excel spreadsheet could assist in mapping out the areas the practice covers and grouping patients accordingly.
  • Establish a process for the scheduling staff to follow that allows for grouping of future appointments together on days in which the provider will be in a defined area.
  • When caring for patients in an assisted living or group home, ensure the scheduling staff maintains an accurate list of patients at each facility so patients are seen together when the provider is at the facility.
  • High patient volume within a facility is a great opportunity to maximize provider productivity by designating set facility days.
  • Recruit and hire providers who reside in a high patient population area so they can provide service with minimal travel time.

Interested in improving productivity Geographic Scheduling? Home Centered Care Institute will present a 30 minute HCCIntelligence™ Webinar on Wednesday, September 18 at 4 pm CST followed by Virtual Office Hours.

 

 

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HCCIntel Practice Management Tip of the Month Training & Education

Why is HCC Coding so Important for Home Care Medicine?

Medical coding

Medical coding

A hot topic in health care today is Hierarchical Condition Categories (HCCs), and there is no better time to consider the value of HCC coding to your home-based primary care program!  HCC coding is the risk adjustment method used by Centers for Medicare and Medicaid Services (CMS) to determine the annual payments for patients in Medicare Advantage plans.  HCC risk adjustment uses predictive modeling to determine the severity of patients’ conditions, health risk, and status to project the cost of health care coverage for that population.  This is how CMS determines cost savings for patients enrolled in Accountable Care Organizations and the Independence at Home Medicare Demonstration, and HCC risk adjustment will also determine into which Practice Risk Group patients will be placed for the new Primary Care First Model.

Correct diagnosis coding is always important, but it is critical for accurate risk adjustment because it drives appropriate reimbursement for provider services in value-based payments.  An easy “best practice” to initiate is to always code to the highest specificity.  Unfortunately, Electronic Health Records (EHRs) complicate this because the search list populated for diagnosis codes frequently brings the unspecified codes to the top of the list. To overcome this challenge, we recommend creating a list of HCC diagnosis “favorites” that will more easily display for selection. Check if your EMR can highlight diagnoses that map to HCC scores.  Partnering with a certified medical coder can assist in ensuring accuracy in the common conditions included as “favorites,” especially for disease combinations such as diabetes with chronic kidney disease. In addition, you can also consider running a diagnosis utilization report to identify your most frequently treated HCC diagnoses and then review and update your problem lists so you can be as specific as possible for patients with those conditions.

Correct coding is essential for accurately predicting future health care costs for patients and ensuring the appropriate reimbursement for providers.

To enhance your understanding of which conditions carry a risk adjustment factor, download our HCC Resource Sheet for Home-Based Primary Care (HBPC) which provides a list of common HBPC diagnoses for HCC scoring.

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HHS To Deliver Value-Based Transformation in Primary Care

Doctor providing primary care in the home to a chronically ill patient

Doctor providing primary care in the home to a chronically ill patient

  |  cms.gov

The CMS Primary Cares Initiative to Empower Patients and Providers to Drive Better Value and Results

Today, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar and Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma are announcing the CMS Primary Cares Initiative, a new set of payment models that will transform primary care to deliver better value for patients throughout the healthcare system. Building on the lessons learned from and experiences of the previous models, the CMS Primary Cares Initiative will reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing overall health care costs. The models were developed by the Innovation Center under the leadership of Adam Boehler and are part of Secretary Azar’s value-based transformation initiative.

“For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision,” said HHS Secretary Alex Azar. “Building on the experience of previous models and ideas of past administrations, these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before. These models can serve as an inflection point for value-based transformation of our healthcare system, and American patients and providers will be the first ones to benefit.”

Empirical evidence shows that strengthening primary care is associated with higher quality, better outcomes, and lower costs within and across major population subgroups. Despite this evidence, primary care spending accounts for a small portion of total cost of care, and is even lower for patients with complex, chronic conditions. Primary care clinicians serve on the front lines of the healthcare delivery system, furnishing services across a wide range of specialties, from family medicine to behavioral health to gerontology. For many patients, the primary care clinician is the first point of contact with the healthcare delivery system. CMS’s experience with innovative models, programs and demonstrations to date have shown that when incentives for primary care clinicians are aligned to reward the provision of high value care, the quality and cost effectiveness of patient care improves.

“As we seek to unleash innovation in our health care system, we recognize that the road to value must have as many lanes as possible,” said CMS Administrator Seema Verma. “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost while allowing clinicians to focus on what they do best: treating patients.”

Administered through the CMS Innovation Center, the CMS Primary Cares Initiative will provide primary care practices and other providers with five new payment model options under two paths:

Primary Care First and Direct Contracting

The five payment model options are:

  1. Primary Care First (PCF)
  2. Primary Care First – High Need Populations
  3. Direct Contracting – Global
  4. Direct Contracting – Professional
  5. Direct Contracting – Geographic

The Primary Care First (PCF) payment model options will test whether financial risk and performance based payments that reward primary care practitioners and other clinicians for easily understood, actionable outcomes will reduce total Medicare expenditures, preserve or enhance quality of care, and improve patient health outcomes. PCF will provide payment to practices through a simplified total monthly payment that allows clinicians to focus on caring for patients rather than their revenue cycle. PCF also includes a payment model option that provides higher payments to practices that specialize in care for high need patients, including those with complex, chronic needs and seriously ill populations (SIP).

Both models under PCF incentivize providers to reduce hospital utilization and total cost of care by potentially significantly rewarding them through performance-based payment adjustments based on their performance.  These models seek to improve quality of care, specifically patients’ experiences of care and key outcome-based clinical quality measures, which may include controlling high blood pressure, managing diabetes mellitus, and screening for colorectal cancer. PCF will be tested for five years and is scheduled to begin in January 2020. A second application round is also planned for participants starting in January 2021.  Read the full press release

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Leveraging the Knowledge and Experience of HBPC Experts to Help Your House Call Program Succeed

Brent Feorene is a practice management expert and consultant in the field of home-based primary care medicine. Home-based primary care (HBPC) or “house calls” are making a resurgence because they better serve the needs of the four million frail, chronically ill, medically-complex, homebound patients in the US who have trouble accessing the traditional office-based healthcare system.

Hospitals sometimes refer to these patients as frequent flyers or MVPs (multi visit patients) because of their frequent trips to the ER and disproportionately high number of hospital admissions and readmissions. Getting primary care to these patients in their home is proving to meet the triple aim of better outcomes, higher patient satisfaction, and cost savings. In this video Brent describes some the unique challenges that hospitals and physician practices face as they consider providing care to patients at home.

HCCI has convened and continues to work with industry experts from around the country to set standards, develop HBPC training and assist providers and hospitals at all levels attain greater levels of success.

If your hospital or hospital system is seeking ways to reduce readmissions and improve it’s bottom line, contact HCCI for assistance and training implementing a house call program.

The Home Centered Care Institute (HCCI) is a national non-profit organization focused on advancing home-based primary care (HBPC) to ensure that chronically ill, medically complex and homebound patients have access to high-quality care in their home. HCCI works with leading academic medical centers, health systems and industry experts to raise awareness of and advocate for expanding the HBPC model by growing the HBPC workforce through education and training and developing a research-based model for sustainable house call program implementation and growth.