Physician payment: present and future The devil of the details

Physician payment:

present and future

“

The devil of the details”

John D. Goodson MD, FACP

Massachusetts General Hospital Harvard Medical School

The future of PC MD payments

My goals

1. Know the origins of RBRVS, our monetary system, and how physician services are

“valued” in “The Game of Codes” 2. Review the rules for E/M codes

3. Learn to use the new IPPE, AWV and TCM service codes and you will benefit. This is a win/win/win

4. The CCM code could fill the final compensation gap

Welcome to the land of

RVUs

Let’s talk about coding:

Kreb’s vs. RBRVS

Key terms

What: CPT (Current Procedural Terminology): What we do, descriptions of services.

Proprietary to the AMA, usage fee.

HCPCS (Healthcare Common Procedure Coding System). CMS rendition of CPT

Why: ICD (International Classification of Diseases): The code assigned to each disease or condition

RVU (Relative Value Unit): The “coin of the realm”

All models of care delivery use

RBRVS building blocks to

calculate the work done

Salary models use the PFS to establish productivity goals/bonus thresholds.

PCMH compensation models derived from the services delivered by each clinician based on the PFS

ACO revenue distribution derived from the relative values assigned to the work done by each clinician based on the PFS

The origins of E/M undervaluation

began at the beginning

The road to RBRVS:

In the beginning…

1983: HCFA chooses CPT as exclusive source for Healthcare Common Procedure Coding system (HCPCS)

1980s: Medicare payment crisis from “usual and customary” payments, Congress reacts

1985: HCFA begins RBRVS study. CPT 4 has 7000 codes (6900 are for procedures)

1987-89: Hsiao study and his assumptions: Payment for work and costs

Intensity = tech skill, mental/physical effort, psychological stress (not time!)

1988: The Harvard Report,

Hsiao and Braun

The Evaluation and Management

dilemma: The compression effect

Pre 1992 E/M 1992 E/M #Vignettes

90017 New, extended 99204 13

90020 New, comprehensive 99205 27

90060 Estab, Intermediate 99213 10

90070 Estab, Extended 99214 11

Hsiao was forced to compress a wide range of

E/M activities into the small range of E/M codes….

The road to RBRVS:

The research basis of policy

• Technical consulting groups (N=17)

Professional societies, 85% proceduralists. Established “relativity” of intra-service work for 400 vignettes

• National survey on 3200 MDs, asked to

compare vignette intra-service intensity to 20-30 other services

• TCGs matched vignettes to existing CPT codes CPT then linked across services by a selected panel of 24 (19 were proceduralists)

• Relatively in families extrapolated from

E/M payment care continues to be

influenced specialists

AMA Relative value Update Committee (RUC)

CMS

Medicare

Payment

Schedule

RBRVS in the “monetary

system” of health care payment

• Weighted system

• Assigns worth = “RVUs” to each CPT code

• 3 components: Total RVUs = W + P + M – Work “…Clinical work…” (52%)

– Practice Expense “overhead” (44%)

– Malpractice “liability insurance” (4%)

RVUs = “coin of the realm”

= units of payment = our “Euros” = $35.8 in 2014

What the RBRVS E/M model

does NOT cover

Non face-to-face care

Telephonic Electronic

Off hours care

Transitions of care

Care management

Disease prevention: screening/vaccinations Counseling/coaching

Health promotion

Prescription management Chronic care management

Is there hope for primary care

CMS recognizes the dilemma faced by primary care physicians

• CPT controlled by AMA

• RUC controlled by AMA and dominated by proceduralists

• Only one E/M code set, new and established used by all MDs

• PC MDs need access to more RVUs…but how??

The future of PC MD payments

Medicare choices for problem

oriented care

SERVICE PATIENT COSTS

Problem focused clinical care : 99201-5 New Patients

99213- 5 Established Patients

Subject to co-insurance and/or deductible

IPPE (Welcome to Medicare) G0402

100% During 1st _{year of Part B}

Enrollment AWV (Annual Wellness Visits)

G0438 (first) G0439 (subsequent)

100% after 1st _{year of Part B}

The future of PC MD payments

2000 2005 2010 2015 2020 2025 2030

IPPE, 2005

TWO Medicare wellness

and prevention service codes

SERVICE PATIENT COSTS

Problem focused clinical care : 99201-5 New Patients

99213- 5 Established Patients

Subject to co-insurance and/or deductible

IPPE (Welcome to Medicare) G0402

100% During 1st _{year of Part B}

enrollment AWV (Annual Wellness Visits)

G0438 (first) G0439 (subsequent)

100% after 1st _{year of Part B}

enrollment

IPPE “Welcome to Medicare”

documentation requirements

1. Establish individual’s medical/family history.

2. Review of the individual’s potential (risk factors) for

depression, including current or past experiences with depression or other mood disorders

3. Measure individual’s height, weight, BMI (or waist

circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.

4. Review functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire

5. PE

IPPE “Welcome to Medicare”

documentation requirements (cont.)

7. Education and counseling based on PMH, RFs, functional/safety status, PE, end of life discussion

8. Provide a written plan for obtaining appropriate services: AAA screening, CV screening, DM screening, nutrition,

PAP/pelvic, EKG, BMD, colon CA screening, prostate CA screening, vaccinations, glaucoma screening

IPPE “Welcome to Medicare”

documentation requirements (cont.)

7. Education and counseling based on PMH, RFs, functional/safety status, PE, end of life discussion

8. Provide a written plan for obtaining appropriate services: AAA screening, CV screening, DM screening, nutrition,

PAP/pelvic, EKG, BMD, colon CA screening, prostate CA screening, vaccinations, glaucoma screening

and mammogram.

But only about 5 % of Medicare

beneficiaries receive an IPPE!

Annual Wellness Visit (AWV)

documentation requirements (2011)

1. Update medical and family history

2. List current providers and suppliers actively involved with individual care

3. List medications, prescription and non- prescription

4. Measure height, weight (BMI), BP and other “routine measurements”

5. Provide a plan of care for screening, vaccination, health promotion

Annual Wellness Visit (AWV)

documentation requirements (2013)

6. Provide a Health Risk Assessment (HRA).

7. Address concerns highlighted by HRA

questionnaire

8. Develop a data base for each patient

-- Retained in your EHR

What is a

Health Risk Assessment (HRA)?

I. Activities of daily living (ADLs) and

Instrumental activities of daily living (IADLs)

--Physical risks: Frailty/fall risk, home safety --Behavioral risks: EtOH, smoking, seat belt use, risk taking

--Self-care risks: Nutrition, dressing, hygiene, medication management

--“Independence” risks: Shopping, food preparation, housekeeping, laundry,

telephone communication, finances.

II. Mental health

--Depression

Key point: AWVs can stand alone or

have an added E/M visit

• The E/M must be submitted with a “-25” modifier.

• The decision to combine service codes can only be made by the clinician. This cannot be done by anyone else!

Example of combining

service codes

• For example:

– 66 year old established patient is seen for Initial Annual Wellness Visit

– The visit also addresses the management of her HTN, DM and hypercholesterolemia. She is on 5 medications. Labs are ordered.

– Coding= G0438 (Initial AWV) + 99214

= 1.50 + 2.43 = 3.93 work RVUs = 8.02 total RVUs

The future of PC MD payments

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99495-6: Transitional Care

Management (TCM) codes:

--Medicare’s incentive to manage patients as they leave facilities an return to home --This is a bundled payment for PC services

for 29 days of care (i.e. the bill can be submitted starting day 30)

99495 TCM services (moderate):

• Communication by direct contact (face to face), telephone or electronically with the

patient and/or caretaker within 2 business

days of discharge

• A face-to-face encounter with 14 days • MDM of at least moderate complexity • Work RVUs = 2.11

• Total 4.82 (non facility) and 3.96

(facility)

99496 TCM services (high):

• Communication by direct contact (face to face), telephone or electronically with the

patient and/or caretaker within 2 business

days of discharge

• A face-to-face encounter with 7 days • MDM of high complexity

• Work RVUs = 3.05

• Total 6.79 (non facility) and 5.81

(facility)

Services (face or non

face-to-face) provided by clinical staff

• Communication

– With the home health agencies and other community services utilized by the patient.

– With patient and/or family/caretaker, education to support self-management, independent living, and activities of daily living.

• Assessment and support for treatment regimen

adherence and medication management.

• Identification of available community and health resources.

• Facilitate access to care and services needed by the patient and/or family.

Services (face or non

face-to-face) provided by the physician or

other qualified health care provider

• Obtaining and reviewing the discharge information (for

example, discharge summary, as available, or continuity of care documents).

• Reviewing need for or follow-up on pending diagnostic tests and treatments

• Interact with other qualified health care professionals who will assume or reassume care of the patient’s

system-specific problems.

• Educate patient, family, guardian, and/or caregiver.

• Establishment or reestablishment of referrals and arranging for needed community resources.

• Assistance in scheduling any required follow-up with community providers and services.

Billing issues:

• TCM codes include all clinical services on the day of face-to-face visit as well as the totality of related TCM

care within the 29 day billing period.

• The day count starts on the day of discharge. For a patient discharged on Wednesday, the professional staff (RN, NP, PA, or MD) has until Friday to contact the patient. Business days exclude holidays.

• Contact counting based on business days, F2F based on calendar days.

Other key points:

• An attempt to make contact (phone or eamail) with the 2 days of discharge is defined as “two or more

unsuccessful attempts at communication…within a

timely fashion.” If the office does not reach the

patient, documentation of attempts should be sufficient.

• TCM codes can be billed by any clinician. No prior relationship is required.

• TCM services can be submitted by the same providers

who submit charges for hospital, rehabilitation or

Workflow: Know discharge date

Patient needs assessed by “smart triage”

No TCM 7 day 14 day

F2F F2F

30 day review 30 day review

Workflow: Smart triage

Patient leaves facility

Patient needs assessed by “smart triage”

No TCM 7 day 14 day

F2F F2F

30 day review 30 day review

Workflow: 29 days work and wrap up

Patient leaves facility

Patient needs assessed by “smart triage”

No TCM 7 day 14 day

F2F F2F

30 day review 30 day review

Team work and pass offs

• Communication and responsibility are essential components

– Patient identification at moment of discharge (day of admission?): MD, CM, RN, Sec, Enterprise…

– Patient contact and triage: MD, RN, CM – Scheduling of office visit: RN, CM, Sec – Office visit: MD

Documentation

• Options

– Templated note

– Paper documentation (can include

documentation elements and tracking of call/visit)

• Who contributes which elements?

– Separate notes accumulating over time? – Shared notes?

The future of PC MD payments

2000 2005 2010 2015 2020 2025 2030

Chronic care management: A

new code for non face-to-face

(NF2F) care

• Available January 1, 2015

• CMS recognizes that there are many

services provided by PC MDs that are not covered in the E/M service code paradigm (i.e. that NF2F care is part of the post visit time included in a service code

Which patients will be eligible for

CCM code billing?

• Any Medicare patient, “expected to live 12 months or until death”

• Patients with two or more chronic conditions

• One CCM provider per Medicare beneficiary • No prior IPPE (Welcome to Medicare) or

AWV (Annual Wellness Visit) is required. • Non Medicare carriers have no obligation to

Other service code exclusions

• Home health care (VNA) supervision (HCPCS G0181)

• Hospice (HCPCS G0182) • TCM services (99495-6)

• All service codes applicable to patients in a facility (e.g. nursing home) settings.

What will be the patient payment

implications?

• Code will be billable for 30 day periods “in which the medical needs of the

patient require establishing,

implementing, revising, or monitoring the care plan.”

• The service will be subject to at 20% copayment (or covered as part of a Medicare Part B supplement).

• Monthly CCM billing can continue

indefinitely without face-to-face contact or renewal of the agreement

What will be required?

• Documentation in the patient’s electronic medical record that all chronic care

management services have been explained and accepted.

• Written consent for communication with other treating providers.

• EHR availability 24/7.

• Communication via telephone or secure asynchronous NF2F messaging.

• EHR documentation of CCM services provided and time spent.

What will the practice/clinician

be expected to provide?

• Continuity of care with a clinician or practice • Care management that provide the following:

– A systematic assessment of medical, functional and psychosocial needs

– A system-based approach for timely delivery of preventive services

– Medication reconciliation, both prescription and non prescription, and a review of interactions and adherence

– An updatable patient-centered plan of care document

What is a plan of care document?

prognosis, measurable treatment goals, and symptom management

• Planned interventions

• Medication management

• Community/social services ordered and how services of agencies and specialists

connected to the practice will be directed/coordinated,

• Identification of the individuals responsible for each intervention

What is still unresolved ?

• Will higher EHR standards be expected such as real time order entry 24/7?

• Who will be expected to deliver CCM

services, MDs, trained case managers? Original proposal includes a job

description.

• Will detailed written protocols be required and what does this mean?

• Will PCMH or the equivalent certification be required and which certifications will be accepted?

What will be the RVU value of the

CCM code?

• How with the RVUs assigned to the CCM service code be distributed?

Work RVUs vs. Practice Expense RVUs

• Practices will have to consider how to

amortize the costs so that those patients who consume higher resources are

balanced by those who consume fewer resources, knowing that all patients will receive a minimum 20 minutes of care every 30 days.

What is the AMA’s CPT doing?

• The AMA’s CPT has developed three CCM service codes for patients with high levels of instability, the option of a F2F visit and the option of expanding the time by 30

minute increments per month. CPT has now collapsed this to one service code but likely only for the most complex

What are the implications for

practice?

• How broadly will CMS pitch this code? To 70% of Medicare beneficiaries or 10%? • Will RVUs be sufficient to scale for small

practices if broadly applicable or for large enterprises if only for the very sick?

• Will specialists use these codes more than PC MDs?

• Will Medicare beneficiaries accept CCM billing?

Medicare payment reforms

For a hypothetical physician with 500 Medicare patients:

Revenue from 99914 (3 visits per patient per year) = 1500 x 3.13 x $35.82 = $168,175

WITH 10% bonus of $1,681= $184,992 Added revenue for subsequent AWVs

= 500 x 3.26 x $35.82 = $58,387

Added revenue for TCMs (60 moderate and 20 high MDM discharges, 60 x 4.82 x $5.82 = $10,359 and 20 x 6.79 x $35.82 = $4,864) = $15,223

Summary points

1. E/M is at a disadvantage in the RBRVS 2. IPPE, AWV and TCM service codes offer

opportunities to improve compensation

3. CMS documentation stipulations are meant to ensure value for beneficiaries

4. Workflow collaboration, communication and responsibility are essential components

5. EHRs must support the workflow and the documentation