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Pierre ScottVice President
Revenue Cycle Management
5th Annual Lourdes Cardiology Services Symposium: Cardiology for Primary Care
1,194,161
Medicare Statistic
*Source: CMS.gov / research
One Year NJ Part B Enrollments 2012*
1966 2014
19.1 Million
54.0 Million
Medicare Growth
*Source: CMS.gov / research
183%
2013
• $747.7 Billion Net Federal Outlays-CMS Programs• 21.6% of the Federal Budget
“Welcome to
Medicare”
AWV(Annual Well Visit)
TCM (Transitional Care
Management)
AWV (Subsequent)
Medicare Initiatives
110 Physicians (22 PCP / IM)
27 Physician Extenders
About LMA
Leverage new Medicare population health initiatives to deliver better healthcare and optimize revenue.
Be conscious of cost and resources available.
Is there an ROI, what is the potential revenue?
Our Strategic Plan:Medicare Initiatives
Medicare Regulatory Interpreter
Wanted:
Rocket Scientist Experience Required!
"Welcome to Medicare“
only within the first 12 months
of receiving Part B.
Introductory Visit
Review medical and social history Counseling about preventive servicesHeight, weight, and blood pressure BMIA simple vision testA review of potential risk for depression An offer to talk about creating advance
directiveA written plan regarding screenings, shots,
and other preventive services as needed
“Welcome To Medicare” Visit
$168.89(G0402 )
Note: During the first year a patient has enrolled with Medicare, he or she is eligible for the “Welcome to Medicare” Visit or Initial Preventative Physical Exam (IPPE).
(M/C Allowable, NJ Area 99)
“Welcome to Medicare”
AWV (Annual Well Visit)
Developing or updating a list of current providers and prescriptions
Height, weight, blood pressure, and other routine measurements
Detection of any cognitive impairment
Review risk factors and treatment options
Review questionnaire - “Health Risk Assessment”
$174.28(G0438)
Note: Annual wellness Visit, including a personalized prevention plan of service (PPPS), first visit.
(M/C Allowable, NJ Area 99)
AWV (Annual Well Visit)
$117.86(G0439)
Note: Annual Well Visit, including a Personalized Prevention Plan of Service (PPPS), subsequent visit.
AWV (Subsequent)
(M/C Allowable, NJ Area 99)
Assign a project lead
Identify patients turning 65 within your PM system through reporting
Send letters to patients reminding them of the benefit
Emphasis placed on “no cost to you” when speaking with the patient
How To“Welcome to Medicare” and AWV
Schedule the AWV during a sick visit
Review scheduled patients prior to visit for opportunity for AWV and Welcome to Medicare
Place visits at the end of your schedule
Dedicate a Saturday
“Welcome to Medicare” and AWV
TCMTransitional
Care Management
From Inpatient Acute Care Hospital
Inpatient Psychiatric Hospital
Long Term Care Hospital
Skilled Nursing Facility
Inpatient Rehabilitation Facility
Hospital outpatient observation or
partial hospitalization
Partial hospitalization at a
Community Mental Health Center.
Transitional Care Management
To
His or her home;
His or her domiciliary;
A rest home; or
Assisted living.
Communication with patient/caregiver within 2 business days
Medication Reconciliation
Hospitalization Reason
Review Discharge Instructions
Schedule face-to-face visit within 7 to14 days based on clinical complexity
TCM Post-discharge
Licensed Clinical Staff Support
Communicate with agencies and community services used by the beneficiary
Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living
Assess and support treatment regimen adherence and medication management
Identify available community and health resources
TCM Office Visit
Review discharge information (for example, discharge summary or continuity of care documents)
Review need for or follow-up on pending diagnostic tests
Refer to specialists as needed
Provide education to the beneficiary, family, guardian, and/or caregiver
Establish or re-establish referrals and arrange for needed community resources
TCM Office Visit Services Furnished by Physicians or NPPs
$233.57(99496)
Note: Medical decision making of high complexity during the service period. Face-to-face visit within 7 calendar days of discharge.
The codes cannot be used with G0181 (home health care plan oversight) or G0182 (hospice care plan oversight) because the services are duplicative.
(M/C Allowable, NJ Area 99)
TCM -7 Day Follow up
$166.37(99495)
Note: Medical decision making of at least moderate complexity during the service period. Face-to-face visit within 14 calendar days of discharge.
The codes cannot be used with G0181 (home health care plan oversight) or G0182 (hospice care plan oversight) because the services are duplicative.
(M/C Allowable, NJ Area 99)
TCM 14 Day Follow-up
CPT Code DescriptionTotal Payment
AmountDistinct Patient
Count
99495 TCM 14 Day $ 63,530 475
99496 TCM 7 Day $ 41,494 237
G0402“Welcome to
MC” $ 4,694 49
G0438 AWV $ 110,059 785
G0439 AWV (Subsequent) $ 29,745 511Total 2015
$249,522 2525
LMA ROI
Improved Revenue
Enhanced Quality: Identify clinical issues early
Preventive Medicine
Improved Cost of Care
Benefits and Opportunities
Data extraction Not all systems have reports needed “Welcome to Medicare” based on approaching Medicare
enrollment year or one year after Medicare enrollment
Patient outreach Can be a burden on existing staff Better to call during evening hours Explanation of the programs can be very time consuming Patient’s lack of interest in the program
Challenges
Office visit capacity
Increasing Administrative Burden on Physicians
(TCM) Hospital reports
Tracking TCM billing. Can not submit a claim before 30 days post visit. If patient is readmitted TCM claim will be denied.
Patients too sick to travel / Transportation issues
Challenges
CPT Code Allowable CPT Allowable Differential
G0402Welcome to Medicare
$168.89 99213 $73.30 $95.59
G0438AWV
$174.28 99214 $108.88 $65.40
G0439AWV Subsequent
$117.86 99213 73.30 $44.56
99496(TCM)
233.57 99215 146.97 $86.60
99495(TCM)
$166.37 99214 $108.88 $57.49
Comparison to Regular Visits
(M/C Allowable, NJ Area 99)
AWV Two/Week
$16k
TCM One/Week
$10K
46 Work Week/Year
Does a Partner Make Sense?
Call Center
Project Leads
Auditing Services
Analytical Support
