Category: Training & Education

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HCCIntel Practice Management Tip of the Month Training Training & Education

Strategies for Telehealth Implementation

telemedicine

telemedicine

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)

Post-Visit

  • 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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HCCIntel Practice Management Tip of the Month Training Training & Education

Agendas for Interdisciplinary Team Meetings

Interdisciplinary team meeting
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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HCCIntel Legislative News Practice Management Training Training & Education

COVID-19 Update 04/08/20 – Additional Key Information and Flexibilities in the CMS Interim Final Rule

In addition to changes in the Centers for Medicare & Medicaid Services (CMS) Interim Final Rule discussed in our previous update, Providers and practices should be aware of the following additional information and waiver flexibilities in the rule:

  • Home Health Agencies can now provide additional services to patients via telehealth if it’s part of the patient’s plan of care and does not replace the needed in-person care as ordered in the plan of care.
  • Hospice Organizations can provide services to Medicare patients via telehealth if feasible and appropriate to do so.
  • Clinicians now have maximum flexibility in determining patient needs for respiratory-related devices and equipment and the flexibility for more patients to manage their treatments at home. The current National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) that restrict coverage of these devices and services to patients with specific clinical characteristics do not apply during the Public Health Emergency. For example, Medicare will cover non-invasive ventilators, respiratory assist devices, and continuous positive airway pressure devices based on the clinician’s assessment of the patient. So, in summary, on an interim basis, CMS will not enforce clinical indications across respiratory (including home oxygen), home anticoagulation management, and infusion pump NCDs and LCDs (including articles).

The above policies include but are not limited to the following:

  • Home Oxygen
  • Continuous Positive Airway Pressure for Obstructive Sleep Apnea
  • Respiratory Assist Devices (ventilators for home use)
  • Intrapulmonary Percussive Ventilator
  • Oxygen and Oxygen Equipment (for home use)
  • Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management
  • Infusion Pumps
  • External Infusion Pumps

For additional information:

Previous HCCI Updates related to COVID-19:

Disclaimer: This information is current as of 4/08/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses our content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region.

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Providing Telephonic and Virtual Care Requirements as part of COVID-19 Precautions

telemedicine female physicianThe Home Centered Care Institute (HCCI) understands that many Home-Based Practices and Providers are increasing the use of virtual and telephonic care as an alternative to face-to-face care, as appropriate, due to the current COVID-19 pandemic.

Though a telehealth waiver is mentioned under recent legislation (H.R.6074 – Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020), CMS initially responded to the bill advising providers to use Communication-Technology Based Services (CTBS) and interprofessional consults.

In the CMS FAQ published on 3/5/2020, Medicare directs providers to use the current CTBS services as a means of telehealth for traditional Medicare purposes. There are, however, exceptions for Medicare Advantage (MA) patients whose MA Plan offers telemedicine as one of their supplemental benefits.

On 3/17/2020, a new Medicare Fact Sheet and FAQ’s (links below) were then published, indicating authority for the expansion of telehealth under the 1135 waiver to pay for Evaluation & Management (E/M) Office visits, Hospital visits, and other specified visits in the patient’s place of residence valid 3/6/2020.

Before billing for E/M Home Visits (CPT Code Range 99347-99350) or Domiciliary Visits, e.g., assisted living and group homes (CPT Code Range 99334-99337), however, please be advised these services are not included on the list of Medicare Telehealth Services. So, in summary, E/M Office visits (CPT Code Ranges 99201-99205 and 99211-99215) can be paid under telehealth, but E/M Home and E/M Domiciliary visits cannot at this time.

Below are the limited services included on Medicare’s list of telehealth services, which Home-Based Providers typically provide and can potentially bill for − if furnished via telehealth using Place of Service (POS) code 02 for telehealth:

  • CPT codes 99495 and 99496 for Transitional Care Management
  • CPT codes 99497 and 99498 for Advance Care Planning
  • Annual Wellness Visits CPT codes G0438 and G0439
  • CPT code 96161 − Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring, and documentation, per standardized instrument.

CTBS Services and E-Visits (CPT Code Range 99421-99423) can be provided and billed for now and prior to the telehealth waiver without Medicare telehealth restrictions.  We’ve detailed the requirements to bill for these services below (currently, and per the 2019 Medicare Physician Fee Schedule Final Rule, there is no frequency limitation for G2012 and G2010):

G2012: Brief Communication Technology-Based Virtual Check-in

  • Includes a minimum of a 5-10-minute medical discussion by a physician or other qualified healthcare professional (e.g., Advanced Practice Providers) with the patient/caregiver; this cannot include clinical staff time
  • Communication may be audio-only (e.g., telephone) or two-way video
  • Can only be used for established patients
  • Intended to assess the patient’s condition to determine if a face-to-face (F2F) visit is needed
  • Cannot be related to an E/M F2F visit within the previous 7 days and cannot result in an E/M visit within the next 24 hours or the next available appointment
  • Requires a patient-initiated question or call
  • Verbal patient consent is required, however, please note that, as a result of the Medicare 2020 Physician Fee Schedule Final Rule, only a once-per-year annual consent is required for CTBS services as long as the patient is made aware of possible cost-sharing
  • CMS National Payment Amount: $14.80

G2010: Remote Evaluation of Recorded Video and/or images

  • Pre-recorded image and/or video of sufficient quality provided by the patient or caregiver
  • Requires documentation of consent at least once per year (may be verbal, written, or electronic)
  • Requires interpretation and follow-up to the patient and/or caregiver within 24 business hours (follow-up may be via a patient portal communication, telephone, secure text/email or two-way video)
  • Can only be used for established patients
  • CMS National Payment Amount: $12.27

Please note: In the CMS FAQ published on 3/17/20, CMS clarifies that, while these interactions must be patient-initiated, CMS does condone providers making their patients aware of these services and billing for them, as appropriate. Please keep in mind medical necessity is always a requirement of payment, and documentation needs to support the necessity and decision-making of the care provided.

  • Supporting excerpt from CMS FAQ: “We expect that these virtual services will be initiated by the patient, however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation.”

CMS has explicitly stated that they do not consider Remote Patient Monitoring (RPM) Services and CTBS to be part of their definition of telehealth services. Therefore, you can bill for the above and below additional services without the regulatory restrictions of Medicare telehealth requirements (e.g., originating and distant site, geographic restrictions do not apply).

  • 99451, 99452, 99446-99449 (Interprofessional Telephone/Internet/Electronic Health Record Consultation Services)
  • 99453, 99454, 99457, 99458 (Remote Physiologic Monitoring)
  • 99091 (Review and analysis of physiologic data)
  • 99421, 99422, 99423 (Online Digital E/M by a qualified provider); Please note this service is bundled with Chronic Care Management (CCM); Refer to our 2/19/20 HCCIntelligence™ Webinar “What You Should Know About 2020 Coding Updates!” for further details regarding online E/M services
  • G2061, G2062, G2063 (Online Digital E/M by a nonphysician healthcare professional); Please note this service is bundled with CCM

Other Key Considerations:

  • CMS will not enforce an existing provider-patient relationship to furnish telehealth services. The Department of Health & Human Services (HHS) advised: “HHS will not conduct audits to ensure an existing provider relationship during this public health emergency.”
  • Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency. For more information: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
  • HCCI encourages all Home-Based Providers and Practices to contact their local Medicare Administrator Contractor (MAC) to inquire if they will pay for E/M Home Visits furnished via telehealth under the current telehealth waiver.

For additional information on COVID-19 regulations and legislation, please visit the CMS current emergencies page or contact a member of the HCCIntelligence™ Hotline staff at 630-283-9222 or email [email protected]..

You can also visit the HCCI COVID-19 Information Hub for additional information and resources.

Disclaimer: This information is current as of 3/17/2020. Coding regulations are subject to change annually, and COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population; the Home Centered Care Institute focuses our content on CMS guidelines. All G codes are used for Medicare purposes, and commercial payors utilize a corresponding set of CPT codes.

 

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HCCI and NNPEN Conference: Different Strategies, Shared Vision

HCCI NNPEN joint conference

HCCI NNPEN joint conference

How can Nurse Practitioners (NPs) and others effectively start-up and/or expand a home-based primary care (HBPC) practice? Just ask the participants who attended the February 7- 8 joint conference hosted by the Home Centered Care Institute (HCCI) and the National Nurse Practitioner Entrepreneur Network (NNPEN) in Phoenix.

With NPs being the fastest-growing segment of HBPC providers, the conference provided attendees with critical information on planning and operating a successful and sustainable HBPC practice. Participants brought varying backgrounds and HBPC experience levels to the conference, entitled, “Blueprint for Success: Building and Growing Your Home-Based Primary Care Practice.” The first day concluded with a well-attended “Open Office Hours” segment, where participants were able to ask questions about their specific situations, which invariably applied to many in the room.

The two organizations’ strategies are necessarily distinct. HCCI focuses on professional development for NPs who have a specific interest in HBPC while NNPEN, as Sandy Berkowitz, RN, JD, and Co-founder and CEO of NNPEN, explains, “focuses on supporting nurse practitioners as professionals who want to be their own boss.”

At the same time, though, HCCI and NNPEN have a similar vision. “We share the same vision and passion to create access for a primary care population of frail and elderly patients who are vastly underserved,” Berkowitz continues, “and to explore how advanced practice providers can do well by doing good.”

In sharing her own conference takeaways, Heather Hodge, Director of Education for HCCI, said, “During the conference, I was struck again by how providers are offering HBPC through a variety of business models. It’s not a one-size-fits-all. Plus, people seemed to take something from every session that they could immediately apply to their own situations. Finally, the conference gave people a place to ask their top-of-mind questions and share their successes and challenges, like managing different state laws, payer requirements, and so on. In all, the event helped many see they weren’t alone and that, if they were having an issue, someone else probably was, too.”

For NPs and others with questions about developing or sustaining an HBPC practice, HCCIntelligence™ offers webinars and a hotline at 630-283-9222 and [email protected].

 

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HCCIntel Practice Management Training & Education Uncategorized

Annual Chart Audits Can Greatly Benefit HBPC Providers and Practices

medical charts

medical charts

About this Article:

Regular chart audits can significantly help home-based primary care (HBPC) practices improve their coding accuracy and the quality of their documentation, while also identifying lost revenue due to under-coding or missed billing. In this interview, HCCI’s Brianna Plencner discusses how chart audits can also uncover potential compliance issues and ensure documentation and coding practices are current and appropriate.

Article:

In addition to its education offerings in home-based primary care (HBPC), the Home Centered Care Institute (HCCI) offers consulting services, including chart audits, which are a valuable tool that HBPC practices can use to evaluate provider performance and improve coding and documentation. “A formal audit provides confidential, qualified feedback on a provider’s documentation and coding practices,” explains Brianna Plencner, HCCI’s Manager of Practice Improvement.

A Certified Professional Medical Coder and Certified Professional Medical Auditor, Plencner also holds a diploma in Medical Insurance Billing and Coding. Before joining HCCI, she also served as practice manager for Northwestern Medicine HomeCare Physicians, which was founded by Dr. Thomas Cornwell, CEO of HCCI. HCCInsights recently asked Plencner to share her perspective on the benefits of conducting a chart audit.

HCCInsights: Why would an HBPC practice consider using an outside agency to perform a formal chart audit?

Plencner: First, there are many reasons to conduct routine chart audits. Medical practices can use the audit process to educate providers and staff and foster a culture of continuous quality improvement. Expert reviews of patient charts also promote more accurate and complete documentation and maximize the likelihood the practice will receive appropriate reimbursement for the services provided. Because the home-based patient population is complex, the practice’s coding must fully represent the severity of each patient’s illnesses and all the services rendered. At the same time, the audit process can minimize compliance risks by identifying and correcting billing errors.

In terms of why an outside agency would be used, external auditors inherently provide an objective point of view. Their audit decisions are not influenced by an intimate knowledge of the practice and are solely based on the data examined.

HCCInsights: How does the chart audit process work? What should a practice anticipate?

Plencner: Following the execution of a Business Associate Agreement (BAA)*, a nationally certified medical auditor will first work with you to remotely access your practice’s medical record, review a sampling of patient charts, and evaluate the quality of provider documentation and coding accuracy. Then, after a preliminary conversation with our main contact and/or the leadership at your practice, our experts will conduct a virtual meeting with your providers and practice staff to walk through the charts reviewed and discuss the findings and recommendations.

Practices also have the option of requesting that a consultant travel to their location to provide onsite coaching in coding and documentation. As needed, the consultant can also develop customized documentation tools and training plans and assist with incorporating these into the practice’s procedures. Again, the goal of all these activities is to enhance your documentation and increase your reimbursement.

*Editor’s Note: A Business Associate Agreement (BAA) is a legal document signed between a healthcare provider and contractor/vendor. A provider enters into a BAA with a contractor/vendor who might, in the course of the proposed work engagement, (e.g., HCCI) receive access to Protected Health Information (PHI).

HCCInsights: What types of things do the auditors review?

Plencner: It’s a pretty extensive list. Everything from Evaluation and Management (E/M) coding, to ensure the correct level of service is selected and the documentation supports medical necessity, to whether the necessary information is recorded, and timely signatures have been obtained. The auditor will also check whether all services provided were billed out. These are just a few examples of what’s typically reviewed.

HCCInsights: Based on your personal experience, what are the most common issues discovered during a formal HBPC chart audit?

Plencner: Among the top issues we typically discover are: (1) failure to document a complete history of present illness (HPI); (2) failure to document all services being provided, such as reviewing patient records and history, talking to other providers, ordering tests, etc., which is important for determining the correct level of Medical Decision Making (MDM); and (3) under-coding** the correct level of service, which – believe it or not – is actually more common in HBPC practices than over-coding.

**Editor’s Note: Under-coding” is reporting a lower level of service than the documentation supports.

HCCInsights: It seems like there are changes to billing and coding nearly every day – how do auditors keep up?

Plencner: Nationally certified medical auditors are required to complete a variety of continuing education requirements every year to maintain their accreditation. As experts in their field, HCCI auditors actively participate in coding and documentation “boot camps,” webinars and other credential-specific programs.

HCCInsights: Are chart audits required or optional?

Plencner: At a minimum, internal chart audits are a required component of a practice compliance plan. The industry standard is an annual audit of 10 charts per provider to determine coding accuracy and compliance. Practices without an internal billing staff, or practices desiring an unbiased third-party review, would find a lot of value from doing an external chart audit.

HCCInsights: Does HCCI offer other types of consulting services?

Plencner: Yes, HCCI can conduct practice assessments to evaluate operational standards, clinical functions, policies and procedures, and opportunities for improvement. All our consulting services are customized to the practice’s specific needs and concerns. We also can offer practices customized education, such as exclusive webinars and onsite, interactive training for the entire team.

HCCInsights: How would a practice learn more about initiating a chart audit through HCCI?

Plencner: Call us at 630-283-9222 or email  [email protected]. After an introductory call with your team, HCCI will be happy to provide you with a proposal that outlines the recommended scope of work and describes next steps. 

Editor’s Note: Those interested in coding will also want to attend our free HCCIntelligence™ webinar this month (Wednesday, February 19, 4:00 pm-5:00 pm Central Time) featuring the topic, What You Should Know about 2020 Coding Updates!

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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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New HCCI Online Course Helps Take the Mystery Out of Home-Based Primary Care

About the Article:

Have you ever wondered what a career in home-based primary care would be like? According to Heather Hodge, Director of Education for the Home Centered Care Institute (HCCI), the organization’s new online course, House Calls 101: An Introduction to HBPC, is a great way to find out.

Article:

While home-based primary care (HBPC) is a growing field, many providers may not fully appreciate the numerous benefits of seeing patients in a home-based setting, nor understand how practicing within an in-home environment may differ from an office-based setting. In addition, many HBPC practice managers and operations staff are seeking a better understanding of house call components.

The Home Centered Care Institute’s (HCCI) new online course, House Calls 101, was developed to offer providers, practice managers and operations staff the unique opportunity to virtually shadow an HBPC physician and her medical assistant on a simulated house call.  The course also provides a detailed breakdown of the steps to be taken before, during, and after a home visit, and offers insight into the characteristics and personal qualities of successful HBPC providers.

House Calls 101 is HCCI’s newest online course.  According to Heather Hodge, HCCI Director of Education, the course was developed as a tool to expand the HBPC provider talent pool and give practice managers and operations staff a closer look at what goes into a house call.  “Only about 15% of the patients who truly need HBPC services receive them,” Hodge said, “which correlates directly to the need to expand the HBPC provider network and provide a strong practice management foundation.”

Hodge’s background in the design and development of continuing medical education programs played a key role in creating the 30-minute course. She sat down with HCCInsights to discuss her perspective on the course and its ability to realistically demonstrate what it’s like to be an HBPC provider.

HCCInsights: What was the main objective behind the development of the course?
Hodge: The course is part of HCCI’s overall commitment to developing the HBPC workforce. The demand for HBPC providers currently exceeds the supply, but not every provider is suited for a career in HBPC.  We created this course to give prospective HBPC providers, practice managers and operations staff a realistic and impartial look at what HBPC is like in the real world.

HCCInsights: What are some of the unique features of the course?
Hodge:  It’s more of a primer or introduction to HBPC in general versus some of our other online course offerings that focus on one specific topic, such as Telehealth or Coding. It also introduces video as part of our instruction material for the first time — and is highly engaging with interactive elements.

HCCInsights: What do you think course participants will find most valuable?
Hodge: House Calls 101 de-mystifies the house call process. It walks through each of the main components of a house call ─ from preparing for the day all the way through to completing post-visit activities. In addition, the course covers what it’s like to travel with a Medical Assistant (MA) and takes a deep dive into the Social Determinants of Health (SDOH) that can significantly impact a patient’s health and well-being, and health care utilization. Finally, the course profiles the characteristics and personal qualities required to be successful as an HBPC practitioner.

HCCInsights: Why is it important for HBPC providers, practice managers and operations staff to understand the “Geriatric 5Ms” covered in the course?
Hodge: The “Geriatric 5Ms” is a framework for caring for complex patients. It aligns perfectly with the home-based primary care model; this is what the providers do every day.  It focuses on key areas: Mind, Mobility, Medications, Multi-complexity and Matters Most. These areas are critical to understand because most HBPC patients are older adults with multiple chronic conditions and functional impairments.

HCCInsights: Can course participants earn CME by taking House Calls 101?
Hodge: Yes. House Calls 101 was planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of PeerPoint Medical Education Institute, LLC and HCCI.

To learn more about House Calls 101: An Introduction to HBPC and to register, click here.

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HCCI House Call Practicum™ Helps Set Providers up for Success

Providers with patient and caregiver

About this Article:

Learn more about the HCCI House Call Practicum™ from one of its recent participants. The program offers a unique two-day ridealong, an individualized educational experience offering learners the opportunity to shadow both direct clinical care and back-office practice support.

Article:

Home-Based Primary Care (HBPC) describes the field of providing quality medical care in the home to patients who have difficulty obtaining, or are completely unable to access, office-based primary care. This is typically because they are frail, chronically ill, functionally limited and/or homebound. This type of care can provide many benefits, including the reduction of emergency room visits and hospital readmissions, along with improving overall health outcomes and reducing health care costs. One of the main goals of the Home Centered Care Institute (HCCI) is to educate providers and practices in providing HBPC, oftentimes referred to as “house calls.”

The HCCI House Call Practicum™, one of HCCI’s educational offerings, allows participants to acquire new knowledge and skills in house call operations and clinical care for medically complex patients in the home. For those considering adding house call services to their practice, the Practicum illustrates key fundamental processes, systems and approaches. For those already practicing HBPC, the Practicum provides an opportunity to improve upon what they’re currently doing by learning directly from leaders in the field.

Earlier this year, Lynn Simpkins, Nurse Practitioner, Bon Secours Health System, participated in the Practicum with Cleveland Clinic, an HCCI Center of Excellence for Home-Based Primary Care and Practice Excellence Partner™. Simpkins has built her 30+ year career as a family and geriatric nurse practitioner and is currently focusing on home-based care. She recently shared takeaways from her Practicum experience with HCCInsights.

HCCInsights: What are some challenges that you face daily with your HBPC practice?

Simpkins: Like most providers, we have the challenge of a sick patient population but with the added complexity of providing those patients with care in a home setting. Social, financial and unique medical challenges all play into what we need to address.

HCCInsights: Why did you decide to participate in the HCCI House Call Practicum™?

Simpkins: In addition to the challenges I mentioned, during my work with our HBPC program, our practice has grown more than threefold. This growth has been amazing but posed challenges for us in keeping up with the demands that come with that success. Seeing how Cleveland Clinic manages its patient population of over 2,500 individuals helped me to find ways to apply a similar approach that will work for our team and allow us to successfully scale our program.

HCCInsights: What was Day One of the Practicum like?

Simpkins: I spent most of the first day with a nurse practitioner in the field going on house calls. My first impression of Cleveland Clinic’s program was that everything — systems, care, planning— seemed to be calm and seamless.

The technology used, including the software, also set the team up for success to best serve patients. It allowed the nurse practitioner I shadowed to be much more efficient because she was not constantly asking and answering questions through chats or over the phone, having to chart in another system, or needing to deal with connectivity issues.

It was also good to see how they managed one challenge associated with house calls that we previously faced – namely scheduling. We were giving our patients specific appointment times.  However, it’s difficult to correctly estimate the amount of time needed to treat cases while factoring in traffic and other unforeseen circumstances. This led to us often being late. The Cleveland Clinic team schedules appointments in four-hour windows, which gives the provider some breathing room.

And, most important, the patient care during the house calls was, in a word, “fantastic.”

HCCInsights: After the first day, it sounds like you had a good sense of Cleveland Clinic’s care model. What did Day Two offer?

Simpkins: I spent time in the practice’s office with an administrator learning about their systems, guidelines, safety protocol, and more. This body of work is the core of what makes them so successful and able to offer great care. The administrator I worked with was so giving of her time and very transparent, which helped me see the inner workings of their processes and procedures.

I also had the chance to get a good overview of their back-end practices, such as how a referral is sent, how they handle emergencies, and how they manage their monthly staff meetings and training schedules. I also saw how their nurses triage patients over the phone to determine if they need to go to the hospital or can be cared for by an HBPC provider. Plus, I learned a lot from their billing team about their practices.

HCCInsights: What were you surprised to learn during the Practicum?

Simpkins: One of the most surprising, yet incredibly useful, things I learned about, as I mentioned previously, was their block scheduling in four-hour increments. In the past, we had many patients refuse appointments because the proposed times didn’t work for their schedule. Cleveland Clinic sets visit expectations with their patients from the beginning. It was clear that block scheduling benefits both patients and providers.

HCCInsights: Were there any learnings from the Practicum you were able to implement right away in your practice?

Simpkins: Yes, we started reviewing some of our procedures right away, like our safety guidelines, and began to apply what I learned. We have also continued to implement the teachings from the Practicum throughout the year. For example, right now, we are working to move nurses away from scheduling so that they can focus solely on clinical work.

HCCInsights: What would you tell future Practicum participants?

Simpkins: The program is very worthwhile no matter what stage of practice you are in – because the activity is very individualized. For example, if you are currently offering HBPC, it gives you an opportunity to improve. If providing home care is new to you, you can begin with strong principles and practices from day one.

____________________________________________________________________________

To learn more about the HCCI House Call Practicum™ program and/or register, click here. There’s also an optional one-day Telemedicine Elective shadowing opportunity, also presented by Cleveland Clinic, that can be added on to the two-day Practicum, or attended on its own.

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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