Chronic Care Management under CPT® Code 99490

Transcription

Chronic Care Management under CPT® Code 99490:
How to Improve Patient Engagement and Increase
Reimbursement
Bill Sillar
National Channel Manager, McKesson
Business Performance Services
May 11, 2015
Today’s Speakers
Bill Sillar
National Channel Manager, McKesson’s Business
Performance
Bill is responsible for supporting McKesson’s Value Based
Care solutions.
Bill has been with McKesson for over 10 years. During his
tenure, Bill has had a pivotal role helping healthcare
organizations bridge the gap as they transition from a fee-forservice to a value based reimbursement.
2
Rev
8/12/15
McKesson Corporation Confidential and Proprietary
Learning Objectives
Industry trends and how chronic conditions are
impacting Medicare spending
About Medicare’s CCM program requirements and
reimbursement incentives
How to qualify and receive compensation for
CCM services
How to calculate your organization’s potential
revenue from CCM reimbursements
How to evaluate the implementation options that allow
for a successful CCM program
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© 2015 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved.
Chronic disease by the numbers
46%
75%
of US healthcare
spending is on
people with chronic
conditions
of all Medicare spending
in 2010 came from those
beneficiaries with 6 or
more illnesses
14% of Medicare
beneficiaries have 6 or
more chronic conditions
7 out of 10 deaths among Americans each year
are from chronic diseases
4
More than
two-thirds
of the current 54 million
Medicare beneficiaries
have 2 or more
chronic conditions
In 2015, the U.S. Department of Health and Human Services (HHS):
30% of all Medicare payments will be
value-based by 2016
50% of all Medicare payments will be
value-based by 2018
85% of Medicare fee-for-service
(FFS) payments will be tied to quality
and value by 2016
90% of Medicare FFS payments will
be tied to quality and value by 2018
By 2022, Medicare beneficiaries are expected
to compose 58% of provider volumes
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Source: http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-forshifting-medicare-reimbursements-from-volume-to-value.html
Transitional engagement programs
6
•
Most providers need programs that allow
them to move towards a value-based ideal
while still operating in a
fee-for-service reality
•
Risk stratification is widely gaining traction as
a means of identifying patients for targeted
outreach
•
“Pay-for-Prevention” initiatives needed to
bridge the volume to value gap
Payment reform for CMS’ new CCM program
CMS has acknowledged the
importance of chronic care
management (CCM)
• Patient outcomes
• Cost savings
Services can be
fulfilled by the provider
or performed by a third party.
Under CPT® code 99490, CMS
pays separately for monthly,
non-face-to-face care coordination
services furnished to
Medicare beneficiaries
with 2 or more
chronic conditions.
Average reimbursement
from CMS for a CCM care
coordination event is approximately
$40.00 per enrolled patient per month.
CPT® is a registered trademark of the American Medical Association.
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Who is participating now?
November 2015: Already
increased to 26% have
implemented
October 2015: 17%
have implemented
8
Rev
8/12/15
• Another 23% said they
planned to evaluate CCM
programs in the near future
McKesson Corporation Confidential and Proprietary
2016: With current trends
from both CMS and
commercial plans
indicating a strong growth
and continued focus on
VBR (value-based
reimbursement) the time
is now to begin these
steps to VBR.
Chronic Care Management (CCM)
CMS’ Regulation Overview
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CMS basic criteria for a CCM program
Patients
• Must provide their consent
• Must have 2 or more chronic conditions
• Medicare co-pay of 20%; an estimated
$8.52 based on the national average
reimbursement for CPT 99490
• Can only participate in one provider’s
CCM program
Providers
• Must maintain patient records using
certified EHR technology
• Must explain the scope of CCM services
directly and how to revoke consent
• Must initiate CCM as part of an annual
wellness visit (AWV), initial preventive
physical exam (IPPE) or comprehensive
E/M face-to-face visit
• Must provide on-call service or 24/7
urgent care with access to the patient’s
electronic medical record
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What do CCM services entail?
A minimum of 20 minutes, monthly, of non-face-to-face services
including all of the following program components:
Comprehensive Care Plan
Medication Reconciliation
Transition of Care
Care Coordination between Providers
24/7 Access to Urgent Care
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Eligible visit types
CCM Services must be initiated as part of a face-to-face visit. These visits can
either be a comprehensive wellness exam, such as an Initial Preventive Physical
Exam (IPPE), Annual Wellness Visit (AWV) or Evaluation and Management (E/M)
visit; or a Transitional Care Management (TCM) visit.
IPPE/AWV
E/M
TCM
•
G0402
•
99212
•
99495
•
G0438
•
99213
•
99496
•
G0439
•
99214
•
99215
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Who can provide services?
Only specific providers can
bill for CCM services
These providers can
supervise other clinical staff in
the execution of these
services:
Nurses (RNs, LVNs, LPNs)
Physicians
Medical Technicians (CNAs,
MAs)
Advanced Practice Providers
(Nurse Practitioners, Physician
Assistants, Certified Nurse
Midwives, Clinical Nurse
Specialists)
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Pharmacists and Pharmacy
techs
Other credentialed clinical staff
Benefits of Participating in
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Multiple advantages to participating
Higher Quality
of Care
New Revenue Steams
The “Paid for Petri Dish”
(AWV, IPPE, E/M, and CCM)
• Population Health Management
• Risk-based Contracts
• Shared-savings (Current ACOs)
• Increased volume and primary
interventions
ROI for hard to quantify
outreach programs
• Decreasing avoidable utilizations
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Increase in Primary
Care Physician (PCP)
volume
Single provider estimated gross revenues
Based on national averages
Annual *
Physician
Provider Count
1
Average CCM PMPM Reimbursement
$40.00
Assumed amount of enrollees in CCM
50
Estimated Revenues – CCM Services
$24,000
Estimated Cost – CCM Services
?
*Assumes approximately 50 patients per month. Average 300 Medicare patients per Physician, reduced by CMS’ estimated
66% of patients with 2+ chronic conditions and an estimated 25% acceptance rate.
To calculate your CCM revenue, visit:
http://www.mckesson.com/ccm-calculator
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Payment and Payment Specifics
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What you need to provide to bill CCM
Better Patient Surveillance and Care Coordination
Monthly Care Plan Updates
24/7 Online Access to Care Plans
Monthly Medication Reconciliations
Facilitated Care Transitions
Compliance Oversight
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Overlapping services
There are some CPT
codes whose services
overlap with those
delivered through
CCM
CMS does not allow
providers to bill for
these codes in the
same month as CCM
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TCM
• Transitional Care Management, 94945
• Transitional Care Management, 94946
CPO
• Home Health Care Supervision, G0181
• Hospice Care Supervision, G0182
ESRD
• End Stage Renal Disease Services
• 90951-90970
Remote
• Analysis of Clinical Data, Computers, 99090
• Collection & Interpretation of Physiologic Data, 99091
CMS’ CCM billing guidelines: 99490
What date do we use for billing 99490?
99490 can be billed once the 20 minutes of service have been delivered or at the end of the month. The provider
may choose the exact date as long as the 20 minute requirement has been met prior to submitting the code.
What place of service should be used when billing 99490?
An outpatient non-facility based provider should use the code for their primary office location as the place of
service (POS) for CCM.
Can I bill for CCM for my patients that are in the hospital or other inpatient facility?
No. Payments made for other facility based services include care management and care coordination so this
would be considered overlapping service coding.
Can I bill for CCM if the beneficiary dies during that calendar month?
Yes, if the 20 minutes of services have been delivered prior to the beneficiary’s death and all other billing
requirements have been met then a provider can bill the 99490 code.
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Outsource vs. In-house
Extensive resource requirements:
20-minute outreach for 50-100 pts. (16-32 hours per month)…no
patient keeps to just 20 minutes!
Identification of applicable 2+ chronic illness Medicare patient pool
Outreach to schedule patients for AWV/IPPE/E/M and CCM enrollment
Educational & marketing material created and disseminated
Consent form signed, create care plans, medication reconciliation
Updating care plans monthly
Transitional care and care coordination
Billing, coding, co-payment collection
24/7 access
Ability to flex FTEs based upon positive growth of CCM program
Non-clinical oversight (nutritionist, health coaches, etc.)
Documents all times, dates, and interactions had with patients
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McKesson Chronic Care Management
Services™
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The McKesson difference
Better Patient
Surveillance
and Care
Coordination
• We know that you are short
on staff and time. We are
here to fill that gap and be
an extension of your office.
Monthly
Medication
Reconciliations
• We work to identify whether
patients are adhering to their
medication schedules and
following the protocol that
has been set out for them.
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Monthly Care
Plan Updates
• We create a care plan with
our clinical staff and
coordinate that with your
patients. We issue a monthly
update so the physician
knows every detail of that
plan.
Facilitated Care
Transitions
• We facilitate all care
transitions, which means you
can bill more Transitional
Care Management codes.
24/7 Online
Access to
Care Plans
• Physicians can log into our
web-based software solution
and view their patient’s care
plans anytime from their
computer.
Monthly Billing
• Each month the
practice receives an invoice
for patients that meet CMS
Chronic Care Management
billing criteria. You bill for the
services and keep the 56%
ROI.
Thank You!
For questions, email
[email protected]
24
Thank You!
Bill Sillar, National Channel Manager
McKesson Business Performance Services
Contact Us at 877-217-9199
mckesson.com/bps
[email protected]
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currency of or for any errors or omissions in the information.
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© [2015] McKesson Medical‐Surgical Inc
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Chronic Care Management under CPT® Code 99490

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