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3/28/2016

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Peter Hollmann MD

Past CPT Panel Chair

Evaluation and Management – Emerging Trends

© 2016 American Medical Association. All rights reserved.

Disclosures

• Ambassador for AMA CPT

• Member RBRVS Update Committee

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Evaluation and

Management

3 © 2016 American Medical Association. All rights reserved.

Evaluation and Management – The History

• Created for CPT 1992

– CPT E/M Guidelines, Preventive Medicine Codes also 1992

• 1995 HCFA Documentation Guidelines

• 1997 HCFA Documentation Guidelines

• E/M Workgroup 2002-2004

• Rise of Electronic Records

• Recognition Non Face to Face and Team Care

• Care Management and PCMH

• Medical Decision Making 2014

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E/M - The reality

• 2010 total Part B spend $110B

• 2010 Part B on E/M $33.5B

• A substantial portion of “surgical” procedures is unreported E/M

– Actual post op visits or similar services in pre/post time

• Used by all specialties (almost) and non physician professionals

• Due to budget neutrality any change in E/M will be paid for from E/M

• Intra-specialty consistency vs. inter-specialty consistency

• Fundamental structure is single problem focused H+P – the Medical Student Approach to Coding


2012 PFS Proposed Rule (July 2011)

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Professional Response

• Meet with CMS to better understand request and educate

• Recognize established codes (e.g., warfarin management)

• Recognize monthly fee for PCMH

• CPT/RUC will create/value codes that address non F2F time and care

management

• Discussed only and not proposed – Revise E/M

– Acute care

– Chronic care

– Post op global care


Goals of New Services

• Recognize work and practice expense of chronic care management

– Non F2F

– Electronic Records

– Advanced Primary Care

– Team care and efficient practice at the top of the license

– Patient/caregiver involvement

• Stimulate transformation of the delivery system

• Primary Care orientation without creating specialty specific codes

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B Status

• 99339-99340 CPO (other than homecare, hospice, NF) – 2006

• 99358-99359 Prolonged Services Non F2F – 1999

• 99363-99364 Anticoagulant Management – 2007

• 99336-99368 Medical Team Conferences – 2008

• 99379-99380 CPO Nursing Facility – 1999

• 99441-99443 Telephone – 2008

• 99444 On-line – 2008

• 99446-99449 Interprofessional Consultation – 2014

• 99487-99489 Complex Chronic Care Management - 2013


Medicare Statutory Benefit and Other E/M like Codes

• Welcome to Medicare Physical (G0402)

• Annual Wellness Visit (G0438-G0439)

• Preventive Services Screening/counseling (many G codes)

• CPO Home Care and Hospice (G0181-G0182)

• Certification/recertification of home care (G0179-G0180)

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New Paid Services Since Proposed PFS 2012 Rule

• 99495-99496 Transitional Care Management – 2013

• 99490 Chronic Care Management – 2015

• 99497-99498 Advance Care Planning – 2016

• 99415-99416 Prolonged Professional Staff Services - 2016

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Evolving Concepts

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2016 PFS Proposed Rule



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Under Consideration

• Dementia Assessment

– Guideline driven, quality measure, E/M does not describe service adequately

• CCM based on Professional Time

– CPO when not HH or Hospice (or CCM is N/A or less favorable)

• Non F2F Acute Care Episodes

– NF and home/dom/ALF

• Principle Care CCM

– CCM without two or more conditions, not PCP

• MTM in a physician/QHCP office

– Using pharmacists outside of Part D

• Behavioral Health Co-Management/Assistance

– Community Based Consult Services applied to PCMH embedded MH clinicians

• Unusual Complexity E/M add-on

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Putting Newer

Codes into Practice


Newer Services – Coding and Tips

• TCM

• CCM

• Advance Care Planning

• Prolonged Clinical Staff Services

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Transitional Care

Management


TCM - New in Final Rule 2016

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TCM – The Patient

• DISCHARGE FROM

– IP Acute Care Hospital

– IP Psychiatric Hospital

– LTC Hospital

– SNF

– IP Rehab Facility

– Hospital Outpatient OBS or

Partial Hospital

– Partial Hospital at CMHC

• DISCHARGE TO

– Home

– Domiciliary

– Rest Home

– Assisted Living Facility


Required Services

• Interactive Contact

– Within 2 business days: F2F, phone, e-mail

– Must make 2 attempt within 2 business days

• Certain Non Face to Face Services

– Necessary services for transition (eg record review, care coordination)

• A face to face visit

– Within 14 days

– Medication Reconciliation required by required F2F date

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TCM Rules

• 30 days (Date of Discharge is Day#1)

• First F2F visit is not reported separately; additional E/M may be

reported

• Only one professional may report

• Not to be reported by professional who is providing services within a

global period

• The discharge day services may not constitute the initial F2F visit

• May not report Certification (G0179-G0180), CPO (G0181-G0182), or

ESRD (90951-90970)


TCM – Code Selection

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TCM – Medical Decision Making

• Over the 30 day period – not the initial F2F

• Uses E/M Guidelines to Define Level of MDM


TCM- Medical Decision Making Over the 30 days

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TCM- Who may report and Documentation Required


TCM – Who may REALLY report

• The “physician” (MD/DO or qualified NP, PA, CNS, or CNM) is to

“oversee management and coordination of services, as needed, for

all medical conditions, psychosocial needs and activity of daily

living supports…” for the full 30 days post discharge (c.f. MPFS

Final Rule, CY 2013, p. 313)

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TCM- Should you Report?

CODE FEE (NF)

99214 $108.20

99215 $145.82

99495 $164.81

99496 $232.52


TCM- Should you Report?

CODE FEE (NF) CODE FEE (NF) SUM

(G+G+E/M)

99214 $108.20 G0180 $54.10 $271.22

99215 $145.82 G0181 $108.92 $308.84

99495 $164.81

99496 $232.52

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But CPO is uncommon and Certification + E/M pays less

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TCM Resource (ICN 908628 - June 2013)

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This publication notes

billing on Day 30

Chronic Care

Management

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Chronic Care Management

• TCM and CCM codes created by CPT for 2013

• Medicare accepts TCM and CCM is “B” status

• 2014 Fee Schedule CMS proposes paying a single G code for CCM of 20 minutes or more in a 30 days period, for persons with 2 or more chronic conditions

• Lots of other issues included, eg PCMH and EMR certification and no link to a face to face service

• Apparent goal was high volume, low dollar payments for a large proportion of beneficiaries

• CPT responds with “Medicare code” 99490

• Value $42


Chronic Care Management

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CCM and Complex CCM

CODE 99490 99487

# Chronic Conditions >2 >2

Duration of Conditions 12 months or until death 12 months or until death

Clinical Staff Time > 20 minutes > 60 minutes

Period of service Calendar Month Calendar Month

Comprehensive Care

Plan

Established, implemented,

revised or monitored

Established or substantial

revision

MDM No requirement Moderate or High

Medicare Payment $40.84 B Status


CCM- Who Qualifies

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Role of Physician or QHCP

• Oversees the management and/or coordination of services, as needed, for:

• All medical conditions,

• Psychosocial needs and

• Activities of daily living

• Incident to

• By appropriately qualified clinical staff

• Or personally by provider


CCM Services

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CCM Services


CCM – Care Plan

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CCM- Practice Requirements


CCM – Initiation and Consent

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CCM- EMR Requirements



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CCM - Restrictions

• Not in an Advanced Primary Care Demonstration Project – the Specific

Patient

• Not with other Care Management Service Codes for same time period

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CCM Resource (ICN 909188 - May 2015)

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Advance Care

Planning

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Advance Care Planning (99497-99498)

49 © 2016 American Medical Association. All rights reserved. 50

Advance Care Planning

• For CY 2016, CMS has changed assignment of CPT

codes 99497 and 99498 PFS status to indicator “A,”

(defined as: Active code).

• The presence of an “A” indicator does not mean that

Medicare has made a national coverage determination

regarding the service. Contractors remain responsible

for local coverage decisions in the absence of a

national Medicare policy.

• Medicare allowance is $85.99 and $74.88 for 99497

and 99498 respectively.

© 2016 American Medical Association. All rights reserved. 51

Advance Care Plan 2016 Final Rule

• Separately payable with AWV; use modifier -33 so

beneficiary has no cost sharing

• If done with AWV can also be a team service

• Also separately payable with E/M; use modifier -25 on

E/M (does not include Critical Care)

• CMS allows that the service be “incident to” with some

significant direct supervision


2016 Final Rule

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ACP - additional points

• Standard CPT Time Rules (more than ½ way to midpoint)

• Do not count any time that was part of determining level of E/M as ACP

time

• Does not require execution of a legally recognized advance directive

• No predetermined frequency limits

• No specific special training/specialty restrictions

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Prolonged Clinical

Staff Services

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Prolonged Services: New Codes 99415-99416

Prolonged Service Clinical Staff Services With Physician or

Other Qualified Health Care Professional Supervision

• New title and subsection guidelines

• New timed codes to identify prolonged clinical staff

time of one hour (99415) and each additional half hour

(99416).

• Reported for prolonged clinical staff services service

(beyond the typical E/M service time) during an

evaluation and management service


What has changed for Prolonged Services?

Prior to 2016, codes 99354 and 99355 were

the only codes that could be reported for prolonged services

provided face-to-face with the patient.

These services state that the physician or qualified health care

professional was providing the service.

The development of the new codes allows a method for reporting face-to-face services

that are not provided by the physician/QHP for things that only require

face-to-face observation by clinical staff under the supervision of a

physician /QHP.

Development of the new codes allow for

such reporting under specifically

noted circumstances.


Reporting 99415 and 99416

• The typical face-to-face time of the primary (ie physician/QHCP) service is used in defining when prolonged services time begins

• Less than 45 minutes of prolonged service is not reported separately

• When face-to-face time is noncontiguous, use only the face-to-face time provided to the patient by the clinical staff. Do not count time of CS providing other reported services (except the E/M).

• No more than 2 simultaneous patients

• Physician/QHCP must be present

• Do not report with physician/QHCP prolonged services codes


Prolonged Services: Example

99214 Office or other outpatient visit for the evaluation and management of an established patient, which

requires at least 2 of these 3 key components:

A detailed history;

A detailed examination;

Medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.


Prolonged Services: Example

• Prolonged services begins AFTER 25 minutes (typical time listed in 99214)

99214

• Code 99415 is not reported until at least 70 minutes total face-to-face clinical staff time has been performed

99415• Because 45

minutes of prolonged services must be performed beginning AFTER the typical time

• 25 + 45 = 70

Why?


Total Duration of Prolonged Services Table

Total Duration ofProlonged Services

Code(s)

less than 45 minutes Not reported separately

45-74 minutes(45 minutes - 1 hr. 14 min.)

99415 X 1

75-104 minutes(1 hr. 15 min. - 1 hr. 44 min.)

99415 X 1 AND 99416 X 1

105 or more(1 hr. 45 min. or more) 99415 X 1 AND 99416 X 2 or more

for each additional 30 minutes.

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Prolonged Services: Revised Codes and

Guidelines

Prolonged Services codes and guidelines have been revised and updated for consistency with instructions in the Psychotherapy guidelines and following code 90837.

These changes:

• Further define that codes 99354 and 99355 are prolonged evaluation and management and psychotherapy service(s) rather than just the generic prolonged “services”

• Refer to new codes 99415 and 99416 when reporting prolonged clinical staff services


Medicare Fee

CODE FEE

99415 $8.96

99416 $0.72

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