david voran - new codes teeing up digital health
TRANSCRIPT
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CMS’ New CPT Codes
“Teeing UP Digital Health Care”
DAVID VORAN, MD
February 25, 2015
+OBJECTIVES
Brief Discussion of CPT (Current Procedural Terminology)
Introduce new CPT codes
Review how each code supports digital interaction
Discuss potential actions in KC Area
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CodesHistorical background
+Medical Coding System
HCPCS Codes
Billing codes used by Medicare and monitored by CMS
Based on CPT (Current Procedural Terminology) developed and owned by the AMA
Numbers assigned to every task and service a medical practitioner may provide to Medicare
Established in 1978 as a way to standardize identification of medical services, supplies and equipment
Composed of 2 levels
Level I: Based on and identical to CPT terminology
Owned and Maintained by AMA
Level II: HCPCS codes used by medical suppliers other than physicians
Owned and Maintained by CMS HCPCS Working Group
Healthcare Common Procedure Coding System
HCPCS
+Brief History
Period Billing System
Pre 1960 Paper invoices designed by each physician, group or
hospital
Each had their own internal “coding” system
Submitted to whomever was the payer
Mid 1960’s AMA developed a standardized system, Common
Procedural Terminology CPT, for use by members
1970-1980 Government, 3rd party payers adopted AMA’s CPT
Standardized HCPCS codes for non-physician
services
1996 CPT, HCPCS, ICD-9-CM code sets mandated by
Health Insurance Portability and Accountability Act of
1996
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Codes drive Costs“…we do what we get paid to do”
+Payment Formulas
Term Definition
Conversion factor adjusted for
budget neutrality
$ amount used to convert RVU’s into payment amount adjusted for budget
neutrality to ensure total Medicare payments comply with allowed total
Medicare funding
Facility Reflects the site of service designation
Facility services generally are provided to inpatients or in a hospital
outpatient clinic setting
GPCI
Geographic Practice Cost Index
Used to reflect the variations in the cost of providing services between
different geographic areas.
Different CPCI’s for work, practice expense and malpractice
MP The portion of reimbursement associated with malpractice expenditures
NonFacility Reflects the site of service designation
Generally provided in freestanding physician offices
PE Portion of reimbursement associated with practice expense including
reimbursement for supplies, equipment and non-physician staff
Work The portion of reimbursement associated with physician work
2009 Non-Facility Payment Amount
[(Work RVU * Work GPCI) + (Non-Facility PE RVU * PE GPCI)+ (MP RVU * MP GPCI)]
2009 Facility Payment Amount
[(Work RVU * Work GPCI) + (Facility PE RVU * PE GPCI)+ (MP RVU * MP GPCI)]
+New Codes Facilitating Digital
Health…breaking free of the solitary face-to-face visit
+Codes Driving Digital Health
Transitional Care Management
(99495 and 99496)
Chronic Condition Management
(99490)
Remote Monitoring (99091)
+Transitional Care Management
Communication with response with patient and/or caregiver within 2 business days of discharge
Medical decision making of at least MODERATE complexity during the service period
Face-to-face visit with 14 calendar days of discharge
Ongoing care management (non-face-to-face) for 30 days post discharge
Communication with response with patient and/or caregiver within 2 business days of discharge
Medical decision making of HIGH complexity during the service period
Face-to-face visit within 7 calendar days of discharge
Ongoing care management (non-face-to-face) for 30 days post discharge
99495: Moderate 99496: High Complexity
+Transitional Care Management
RVU’s
Code WRVU N-FRVU Payment FRVU Payment
99495 2.11 4.58 $164.07 3.11 $111.41
99496 3.05 6.47 $231.77 4.50 $161.20
99214 1.50 3.01 $107.83 2.21 $79.17
Work RVU Relative level of time, skill, training and intensity to provide a
given service
Non Facility RVU Freestanding physician’s office location
Facility RVU Hospital owned sites
2009 Non-Facility Payment Amount
[(Work RVU * Work GPCI) + (Non-Facility PE RVU * PE GPCI)+ (MP RVU * MP GPCI)]
2009 Facility Payment Amount
[(Work RVU * Work GPCI) + (Facility PE RVU * PE GPCI)+ (MP RVU * MP GPCI)]
+Chronic Condition
Management99490
+Chronic Condition Management
99490 - 99491 Effective January 1, 2015
Covers remote chronic care management using new CPT code 99490 with monthly unadjusted, non-facility fee of $42.60
Can be bundled with existing CPT 99491 for remote collecting and reviewing patient data $56.92
Total monthly reimbursement of $99.52 per beneficiary per month
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CCM Digital
Requirements
Requirements
1. Use a certified EHR
2. Maintain electronic care plan
3. Ensure beneficiary access to care
4. Facilitate transitions of care*, and
5. Coordinate care across the beneficiaries continuum of care
6. 24/7 Electronic Access to Plan and Services
7. Share plan electronically outside the practice
8. Enhanced communication with beneficiary
Provider is attesting to each
of these capabilities for
providing CCM when claim is
made.
+CCM – Potential Income
Description Average Formula
Annual Unique Pats 3,279 A
% of Medicare Pts 21.85% B
Annual Medicare Pts 716 C = A*B
% with 2+ Chronic Conditions 68.60% D
Annual CCM Pts 491 E = D*C
CCM monthly payment $42.60 F
Estimated gross revenue per Family
Medicine Physicians
$250,999.20 G = (F*12)*E
*Time to provide CCM 147 Hours/mo H=E*0.3
*FTE 0.882 I=(H*12)/2,000
*If contact-based care totally driven by provider … in person visits don’t count
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Digital Opportunities…where brainstorming can take place
+Potential
Patient Apps
Customized for remote
monitoring of specific
conditions
Linked to HIE, Portals
Tracking Devices
Virtual Management Services
Patient Apps
Appointment reminders
Specific contact lists
Condition specific education
Measurement Devices
Transitional management
services
HIE front ends
CCM TCM
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SummaryOr Review
+Summary
Overview of Medical Coding
“New” codes reimbursing virtual/digital interactions
Discussion on how KC Digital Drive could facilitate adoption of
these tools