HCCIntel Practice Management Tip of the Month Training Training & Education

Strategies for Telehealth Implementation


Telehealth is an important clinical delivery model, especially for home-based providers during the COVID-19 pandemic. Here are some practical implementation considerations:

Practice Implementation

  • Consider current and future COVID-related workflow needs when selecting a technology vendor
  • Train staff by conducting mock virtual visits among team members
  • Develop documentation templates and educate staff on documentation and consent requirements
  • Define the scheduling process (e.g., time slot allotments for virtual versus in-person visits)
  • Use support staff to set up the visit with patients/caregivers before connecting the provider

Provider Telehealth Etiquette

  • Conduct visits in a well-lit, private space; choose solid-colored clothing/backgrounds
  • Greet patients as you would normally, consider showing your I.D. badge to new patients
  • Set camera at eye level, maintain eye contact, and explain if and why you need to look away
  • Speak in a normal tone of voice using empathetic speech and body language
  • Keep “lag time” of technology in mind, allow for pauses
  • Communicate next steps (e.g., follow-up appointments, prescriptions)


  • Conduct patient and caregiver satisfaction surveys, analyze feedback
  • Identify outcome metrics (e.g., number of successful visits, phone versus video, technical difficulties, billing level)
  • Discuss challenges and successes with your team
  • Conduct internal monitoring and audits to ensure documentation and compliance requirements are met for all types of telehealth encounters
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Agendas for Interdisciplinary Team Meetings

Interdisciplinary team meeting

Interdisciplinary team (IDT) meetings improve staff communication, encourage teamwork, and promote optimal patient care and outcomes within house call programs. During the COVID-19 pandemic, IDT meetings are especially important for maintaining team cohesiveness. Following a structured meeting agenda can help maximize IDT meeting effectiveness. In addition, brief staff huddles can serve to supplement IDT meetings and address immediate concerns.

Sample IDT Meeting Agenda:

  1. Key Metrics – discuss outcomes and/or clinical quality metrics being used
  2. Hospitalizations – review recent hospitalizations, brainstorm solutions for future
  3. Case Management – social workers, pharmacists, clinical staff, and/or providers present complex cases to initiate action/planning for patient resources
  4. Announcements / Updates – address logistical or operational changes affecting the team
  5. Waste Identification – discuss process breakdowns/inefficiencies, assign team members to strategize solutions
  6. Recognition – encourage team members to acknowledge others who have gone above and beyond or highlight a team accomplishment to end the meeting on a high note

Effective IDT meetings are a proven way to optimize patient care and outcomes, but they require planning, commitment, and time. To access and download a copy of the full IDT sample agenda, click here (new users will need to complete a one-time registration).


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Infection Control in Home-Based Primary Care

As home-based primary care (HBPC) expands across the U.S., we’re reminded of how critical this model of care is, particularly during a Public Health Emergency like COVID-19.  Because of this, and more than ever, HBPC providers must keep infection surveillance, prevention, and control efforts top-of-mind to protect patients, caregivers, household family members, and themselves. To this end, HCCI offers these important reminders for providers about basic infection control strategies:

  • When scheduling appointments, ask about the travel history and current state of health of the patient and all household contacts.
  • Use proper hygiene and follow recommendations for transporting, storing and disposing of supplies.
  • Disinfect the medical bag and supplies before and after every visit.
  • Assess the home environment before entering and use appropriate personal protection equipment (PPE).
  • Position the medical bag and laptop/tablet on clean, dry surfaces, out of reach of children and pets.

For more information about practical infection control strategies for HBPC providers, download HCCI’s Infection Control Resource Guide.  You can also access more information and resources on the HCCI COVID-19 Information Hub, including HCCI’s online course, Infection Control in Home-Based Primary Care, available at no cost now through June 30, 2020.

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Keep Your Practice Financially Healthy

piggy bank and stethescope

Revenue cycle management (RCM) encompasses all the administrative and clinical functions that contribute to the identification, capture and management of patient service revenue. A periodic review of RCM basics may uncover opportunities for process improvement within your organization. Points to consider:

  • Do you have in-house support, or will you outsource RCM, billing and coding functions? If outsourced, do you receive consistent reports and feedback on your practice’s billing and coding?
  • Do your providers and support staff receive ongoing education on Evaluation and Management (E/M) and billing considerations specific to house calls?
  • Are your providers responsible for selecting their own billing codes or do you have an internal coding review?
  • Do you monitor certain services (e.g., time-based) for accuracy and completeness prior to claim submission?
  • Are progress notes locked and signed within 72 hours? Who monitors open encounter lags?
  • How quickly are claims being paid and who follows up on outstanding unpaid claims/denials?

Also, be sure not to overlook the following:

  • Credentialing – Documentation of each payer enrollment process and ensuring all providers are credentialed with each payer.
  • Office of the Inspector General (OIG) Compliance – Section 6401 of the Affordable Care Act (ACA) requires providers to develop and implement a formal health care compliance program.
  • Denial management process – Examine, resolve and/or appeal claims to recover lost revenues.

Finally, remember that, whether managed in-house or outsourced, successful RCM strategies depend on the accuracy and thoroughness of front-end tasks, such as verifying active insurance coverage prior to visits and the effective denial management process mentioned above.


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Optimizing Front Office Operations

Maximize front office efficiency
House Call programs can become more efficient, drive collaboration and enhance overall effectiveness by optimizing their daily operations. These operations can include managing phone calls, paperwork, record requests, and geographic scheduling; confirming appointments and verifying insurance, conducting patient intake and processing referrals, and assisting with practice billing and coding, among other areas.
Here are several tips to help your practice be successful:
  • Develop scripting and decision-tree guides for the front office to follow when speaking with new patients
  • Use real-time eligibility within the Electronic Health Record (EHR) to verify active patients and correct insurance prior to patients being seen
  • Consider using an electronic fax platform with E-Signature capability to streamline orders and paperwork
  • Use clear and concise patient intake and referral checklists to ensure appropriate information is collected in advance and services are explained upon enrollment
  • Define territory zones for each provider and use map-based tools to plan visits and routes
  • Don’t confirm appointments until one week to a few days beforehand to allow for schedule flexibility and ensure patients/caregivers are expecting the provider
  • Explore Health Information Exchange (HIE) options in your area for prompt access to medical records
  • Determine which services may require a review to ensure documentation and coding requirements are met and provide real-time feedback to the providers
  • Taking the time upfront to optimize these operations will prevent task duplication, promote efficiency, and increase patient and team satisfaction.
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Evaluating Your Staffing Model

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

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.


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

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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Geographic Scheduling: Impact on Home-Based Primary Care Productivity

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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Why is HCC Coding so Important for Home Care Medicine?

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.