Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
WHY SHOULD A CHC/FQHC CARE?
• Medicare Part A & Part B• MACRA / MIPS• Chronic Care Management Billing
Suzanne Niemi, CPA, CMPE, CCEAlaska Primary Care AssociationApril 2017
DEFINITIONS
• FQHC – Federally Qualified Health Center• Safety Net Provider that offers services typically furnished in an
outpatient setting:• Community Health Centers• CHC Look-Alikes• Outpatient programs operated by a tribe, tribal organization or
Urban Indian organization
• Organizations must apply for this status
2
DEFINITIONS
• FQHC Medicare Reimbursement• Reimbursement under Medicare Part A through the
Prospective Payment System (PPS)• Paid at a per-encounter rate vs. being paid on the Fee-for-
Service model based on procedure codes
• FQHC-eligible providers must apply to Medicare Part A
3
DEFINITIONS• MACRA = Medicare Access and CHIP Reauthorization Act of
2015• Pay-for-performance program that’s focused on quality,
value, and accountability• MACRA replaced three Medicare reporting programs with
MIPS• Medicare Meaningful Use (MU)• Physician Quality Reporting System (PQRS)• Value-Based Payment Modifier
• MIPS = Merit-Based Incentive Payment System• A performance-based payment system for Medicare Part B
clinicians which requires submission of performance data to CMS
4
DEFINITIONS
• CCM = Chronic Care Management Billing• Reimbursement from Medicare for certain services provided
to patients with multiple (two or more) chronic conditions
5
MACRA and MIPS
6
DOES MACRA /MIPS APPLY TO CHCS?
• Federally Qualified Health Centers (FQHCs) are exempt from MIPS reporting
• Aren’t all CHCs considered FQHCs?• NO !!
• FQHC is a term related to billing / reimbursement methodology• CHCs must apply to Medicare Part A to be recognized and
reimbursed as an FQHC
7
MEDICARE PART A vs. MEDICARE PART B
8
PATIENT ENROLLMENT / COVERAGE FOR SERVICES IN A CHC
CHC Sends FQHC Claims to Medicare Part A
• Patient must be enrolled in Medicare Part B
CHC Sends Fee-for-Service Claims to Medicare Part B
• Patient must be enrolled in Medicare Part B
9
Patient enrollment in Part A covers Hospital, Skilled Nursing, Nursing Home, Hospice and Home Health services
Patient enrollment in Part B covers Outpatient services, Ambulance, Durable Medical Equipment, Mental Health
Patients must be enrolled in Part B for Medicare to cover services provided by an outpatient clinic, regardless of how the provider submits claims
PROVIDER ENROLLMENT
Medicare Part A• Enroll as an organization using Form
CMS-855A• Requires organization level
information • Includes names and information of
governing board members and Executive Director (managing employee)
Medicare Part B• Enroll the group using CMS-Form
855B• Enroll individual providers using CMS
Form 855I
10
BENEFITS OF ENROLLMENT
Medicare Part A• Medicare FQHC per-encounter
reimbursement rates• For non-tribal organizations:
Determines eligibility to receive state Medicaid FQHC per-encounter reimbursement rates
• Do not need to individually enroll providers in Medicare Part A
Medicare Part B• Ability to bill Medicare for services to
beneficiaries• Ability to bill for services not
reimbursable under Part A • (see additional slide for details on
what services cannot be billed to Part A)
11
WHY NOT ENROLL?
Medicare Part A• Some tribal providers have decided
that the reimbursement benefit does not outweigh the reporting burden
Medicare Part B• No services are provided to
Medicare beneficiaries• No services are provided that are
outside of the Medicare Part A scope
12
SPECIAL REPORTING REQUIREMENTS
Medicare Part A• Must submit a quarterly Credit
Balance Report to CMS on Form CMS-838
• Must submit a Medicare Cost report annually 5 months after year end. (much simpler than a hospital cost report)
• Alaska Medicaid requires non-tribal entities to submit a copy of the Medicare Cost Report to Medicaid
Medicare Part B• None• Periodic re-validation required
13
WHAT SERVICES CAN BE BILLED?
Medicare Part A• Services provided to Medicare
beneficiaries furnished by a • Physician• Nurse practitioner (NP) • Physician assistant (PA) • Certified nurse midwife (CNM)• Clinical psychologist (CP)• Clinical social worker (CSW), or • Certified diabetes self-management
training/medical nutrition therapy (DSMT/MNT) provider
Medicare Part B• Most services provided to Medicare
beneficiaries• See next page for exclusions
• Part A providers can bill certain services to Part B (those that cannot be reimbursed under Part A)
14
WHAT SERVICES ARE EXCLUDED?
Medicare Part A exclusionsServices that can be billed to Part B:• Services provided by practitioners other than
those in the previous slide• Laboratory services• Technical components of diagnostic services• Durable Medical Equipment / Prosthetic
devices / body braces• https://med.noridianmedicare.com/web/jea/
provider-types/fqhc/fqhc-billing-guide
Medicare Part B exclusionsSome of the items and services that Medicare doesn't cover at all include:• Long-term care (also called custodial care)• Most dental care• Eye examinations related to prescribing glasses• Dentures• Cosmetic surgery • Acupuncture • Hearing aids and exams for fitting them• Routine foot care
15
HOW ARE CLAIMS FILED?
Medicare Part A• Submitted to Part A using UB-04
• Health Centers are required to use special CPT codes when submitting Medicare claims in addition to regular CPT codes.
• G0466, G0467, G0468, G0469 and G0470
Medicare Part B• Submitted to Part B using CMS-1500
16
HOW IS THE REIMBURSEMENT AMOUNT DETERMINED?
Medicare Part A• Prior to 2014, the Medicare FQHC per-encounter
was cost-based, but was subject to a cap of about $112
• Beginning with fiscal years starting Oct 1, 2014 Health Centers are paid on a Prospective Payment System (PPS)
The rates for 2017:• $163.49 National Base Rate• 1.318 AK geographic adjustment factor (GAF)• $215.48 ESTABLISHED PATIENT VISIT• 1.3416 High Intensity Visit Adjustment• $289.09 NEW PATIENT, INITIAL PREV PHYSICAL
EXAM (IPPE) OR ANNUAL WELLNESS VISIT (AWV)
Medicare Part B• Per the Physician Fee Schedule
updated annually by CMS • The same payment rates as a
private practice provider
17
HOW DOES ENROLLMENT AFFECT THE PATIENT?
Medicare Part A• There is no Part B deductible for FQHC-covered
services
• Coinsurance is 20 percent of the lesser of the FQHC’s charge for the specific payment code or the PPS rate, except for certain preventive services
• Patient cost-sharing requirements for most Medicare covered preventive services are waived, and Medicare pays 100 percent of the costs for these services
• No coinsurance is required for the IPPE, AWV, and any covered preventive services recommended with a grade of A or B by the United States Preventive Services Task Force.
Medicare Part B• Usual Deductibles and 20% Co-Payments
• Same as if they saw a private provider
18
More information on Medicare Part A / FQHC co-insuranceFor a complete list of preventive services and their coinsurance requirements, refer to the Federally Qualified Health Center (FQHC) Preventive Services Chart. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-Preventive-Services.pdf
ARE CHRONIC CARE MGMT SERVICES PAID?
Medicare Part A• Yes• Code 99490 Only
• Cannot bill for new complex CCM codes
• Payment is based on the Medicare PFS national non-facility payment rate.
• The rate is updated annually and has no geographic adjustment
Medicare Part B• Yes• Can bill all CCM codes
19
DOES MACRA / MIPS APPLY?
Medicare Part A• FQHC Medicare Part A providers
are exempt from mandatory MIPS reporting
• Organizations may choose to report
Medicare Part B• MIPS reporting periods begin in 2017
• There are penalties for not reporting
• Payment adjustments (+ or – ) are scheduled to be implemented in 2019 based on 2017 data
20
ARE ALL ALASKA CHCS ENROLLED IN PART A?
Non-Tribal CHCs• Yes. All Alaska Non-Tribal CHCs
have applied for Part A recognition
• Non-Tribal CHCs must receive designation as a Medicare FQHC in order to qualify for state Medicaid FQHC reimbursement
Tribal CHCs• Maybe…
• Tribal Organizations enroll in Medicaid as a tribal entity
• Medicare FQHC enrollment is not required as a condition of enhanced Medicaid reimbursement
• Each Organization makes an individual decision whether or not to enroll in Part A
21
MACRA and MIPSMedicare Access and CHIP Reauthorization Act of 2015
Merit-Based Incentive Payment System
22
MIPS REPORTING REQUIREMENT• “The Quality Payment Program improves Medicare by helping you
focus on care quality and the one thing that matters most — making patients healthier.”
• Federally Qualified Health Centers (FQHCs) are exempt from MIPS reporting
• But, providers may choose to report
• There are over 270 measures to choose from – 55 specifically for General Practice / Family Medicine
• https://qpp.cms.gov/measures/quality
23
MEDICARE PART A
PAYMENT CHANGES BASED ON
MIPS REPORTING
24
• NO CHANGE TO FQHC PER-ENCOUNTER PAYMENT RATES
• For FQHCs, it is important to note that MACRA/QPP implementation will not impact your Medicare FQHC PPS payments
• Because health centers are paid their unique Medicare PPS and are not paid on the Physician Fee Schedule (“Part B”) they will not be subject to MIPS and their payment methodology will not change.
• Health Centers will be able to voluntarily report under the new MIPS, without incentive or penalty.
WHAT ABOUT FQHCs
THAT SUBMIT SOME
CLAIMSTO
PART B?
25
While Part A payments will not be affected, reimbursement for any Part B claims may be affected
• Services that are billed outside of the FQHC benefit and billed to Medicare Part B separately are subject to MIPS.
• Check the low volume thresholds (see slide #27)
MEDICARE PART B
PAYMENT CHANGES BASED ON
MIPS REPORTING
26
MIPS ELIGIBILITYProviders are eligible to participate in the MIPS track of the Quality Payment Program if:• You bill more than $30,000 to Medicare, and • You provide care to more than 100 Medicare patients per year, and • You are a:
• Physician• Physician Assistant• Nurse Practitioner• Clinical Nurse Specialist• Certified Registered Nurse Anesthetist
27
MIPS REPORTING –PARTICIPATE AS AN INDIVIDUAL OR A GROUP?
Individual• One NPI tied to one Tax ID
Group• A group is defined as a set of clinicians (identified by their NPIs) sharing a
common Tax Identification Number, no matter the specialty or practice site.• To submit data through the CMS web interface, you must register as a group
by June 30, 2017.
28
MIPS REPORTING TIMELINE• If you’re ready, you can begin January 1, 2017 and start collecting your
performance data• If you’re not ready on January 1, you can choose to start anytime between
January 1 and October 2, 2017• Whenever you choose to start, you’ll need to send in your
performance data by March 31, 2018• The first payment adjustments based on performance
go into effect on January 1, 2019
29
MIPS REPORTING – CATEGORY #1
Quality (replaces PQRS)• Most participants:
• Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days
• Groups using the web interface: • Report 15 quality measures for a full year
30
MIPS REPORTING - CATEGORY #2Improvement Activities• Participants in certified patient-centered medical homes, comparable
specialty practices, or an APM designated as a Medical Home Model: • You will automatically earn full credit
• Most participants: • Attest that you completed up to 4 improvement activities for a minimum
of 90 days
• Groups with fewer than 15 participants or if you are in a rural or health professional shortage area:
• Attest that you completed up to 2 activities for a minimum of 90 days
31
MIPS REPORTING – CATEGORY #3
Advancing Care Information (replaces Meaningful Use)• Fulfill the required measures for a minimum of 90 days:
• Security Risk Analysis• e-Prescribing• Provide Patient Access• Send Summary of Care• Request/Accept Summary of Care
• Choose to submit up to 9 measures for a minimum of 90 days for additional credit
32
MIPS REPORTING – CATEGORY #4
Cost• No data submission required
• Calculated from adjudicated claims
33
HOW TO SUBMIT DATA
Individual Providers• Send individual data for each of
the MIPS categories through an electronic health record or a registry.
• You can also send in quality data through your routine Medicare claims process.
• https://qpp.cms.gov/learn/getprepared
Groups (registration open from April 1 – June 30, 2017)
Options may vary based on performance category• CMS Web Interface (only available to groups
with 25 or more eligible clinicians)• Qualified Clinical Data Registry (QCDR)• Qualified Registry• Electronic Health Record (EHR)• Administrative Claims• CAHPS for MIPS Survey (only available to
groups with 2 or more eligible clinicians)• Attestation• https://qpp.cms.gov/learn/about-group-
registration
34
MIPS RESOURCES
• https://qpp.cms.gov/
• https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html
35
CHRONIC CARE MANAGEMENT(CCM)
36
CHRONIC CARE MANAGEMENTDefinition:• Services by a physician or non-physician practitioner (PA, NP, Clinical Nurse
Specialist, Certified Nurse-Midwife, and their clinical staff, • At least 20 minutes per calendar month,
• for patients with multiple (two or more) chronic conditions • expected to last at least 12 months or until the death of the
patient, • and that place the patient at significant risk of death, acute
exacerbation/ decompensation, or functional decline. • Comprehensive care plan established, implemented, revised, or monitored• Note that only 1 practitioner can bill CCM per service period (month)
37
EXAMPLES OF CHRONIC CONDITIONS INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING:
• Alzheimer’s disease and related dementia
• Arthritis (osteoarthritis and rheumatoid)• Asthma • Atrial fibrillation• Autism spectrum disorders • Cancer• Cardiovascular Disease• Chronic Obstructive Pulmonary Disease
• Depression • Diabetes• Hyperlipidemia• Hypertension • Infectious diseases such as HIV/AIDS• Ischemic Heart Disease• Kidney Disease (Chronic)• Osteoporosis• Stroke
38
CHRONIC CARE MANAGEMENT SERVICESThe CCM service is extensive, including
• Structured recording of patient health information in a certified EHR• Maintaining a comprehensive electronic Care Plan• Access to Care & Care Continuity• Comprehensive Care Management• Transitional Care Management• Coordinating and sharing patient health information timely within and
outside the practice.
39
COMPREHENSIVE CARE PLANA comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:• Problem list• Expected outcome and prognosis• Measurable treatment goals• Symptom management• Planned interventions and identification of the individuals responsible for each
intervention• Medication management• Community/social services ordered• A description of how services of agencies and specialists outside the practice will be
directed/coordinated• Schedule for periodic review and, when applicable, revision of the care plan
40
2017 FQHC BILLING REQUIREMENTSInitiating Visit:• For new patients or patients not seen within one year prior to the
commencement of CCM,• Medicare requires initiation of CCM services during a face-to-face visit with the
billing practitioner:• An Annual Wellness Visit (AWV), or • Initial Preventive Physical Exam (IPPE), or • Other face-to-face visit with the billing practitioner
• This initiating visit is not part of the CCM service and is separately billed
41
2017 FQHC BILLING REQUIREMENTSThe FQHC must inform eligible patients of the availability of CCM services and obtain consent for the CCM service before furnishing or billing the service. • Patient consent requirements include:
• Informing the patient of the availability of the CCM service• Obtaining written agreement to have the services provided, including
authorization for the electronic communication of medical information with other treating practitioners and providers
• Explaining and offering the CCM service to the patient and documenting this discussion in the patient’s medical record, noting the patient’s decision to accept or decline the service.
• Informing the patient of the right to stop CCM services at any time (effective at the end of the calendar month)
• Informing the patient that only one practitioner can furnish and be paid for the service during a calendar month
42
CCM BILLINGIn November 2016, CMS announced rule changesEnables reimbursement for more complex and more time-intensive chronic care coordination effective January 2017.
HOWEVER, these new codes are not available to FQHCs
• Only CPT 99490 is payable in FQHC and RHC settings.
• Complex CCM is not payable and there is no add-on code/separate payment for initiating visits
43
CCM BILLING CODE FOR FQHCsCPT code 99490• Allows eligible practitioners and suppliers to
bill for • at least 20 minutes of non-face-to-face
clinical staff time • directed by a physician or other qualified
health professionals • each month • to coordinate care for beneficiaries who
have two or more serious chronic conditions that are expected to last at least 12 months.
THIS IS THE ONLY CODETHAT CAN BE BILLED BY Federally Qualified Health Centers (FQHCs)
44
CCM ADDITIONAL BILLING CODES (not available to FQHCs)
HCPCS code G0506 • An add-on code to the CCM initiating visit for
providing a comprehensive assessment and care planning to patients.
CPT code 99487• Complex CCM that requires substantial revision of
a care plan, moderate or high complexity medical decision making, and 60 minutes of clinical staff time.
CPT code 99489• complex CCM add-on code for each additional
30 minutes of clinical staff time.
45
2017 REIMBURSEMENT RATES
46
2017 FQHC BILLING DETAILS
• CCM services can be billed alone or on the same claim as an office visit
• Must be billed on or before the last day of the month• Must include at least 2 chronic condition diagnosis codes• Billed each month that services have been documented. • Does not need to be consecutive months• No revenue code restrictions• Note that time spent must be documented
47
2017 CCM BILLING SUMMARY• FQHCs can bill for CCM services when a FQHC practitioner furnishes a
comprehensive evaluation and management (E/M) visit, Annual Wellness Visit (AWV), or Initial Preventive Physical Examination (IPPE) to the patient prior to billing the CCM service, and initiates the CCM service as part of this visit.
• CCM payment will be based on the Medicare Physician Fee Schedule national average non-facility payment rate when CPT code 99490 is billed alone or with other payable services on a FQHC claim.
• The rate will be updated annually and has no geographic adjustment. • The FQHC face-to-face requirements are waived when CCM services are
furnished to a FQHC patient.
48
2017 CCM BILLING SUMMARY (cont’d)• Coinsurance would be applied as applicable to FQHC claims. • FQHCs would continue to be required to meet the FQHC Conditions of
Participation and any additional FQHC payment requirements. • FQHCs cannot bill for CCM services for a beneficiary during the same service
period as billing for transitional care management or any other program that provides additional payment for care management services (outside of the FQHC PPS payment) for the same beneficiary.
49
CCM BENEFITS TO THE PATIENTThe patient will experience many benefits from participating in the program:• 24 × 7 access to care coordination• Monthly consultations via non face to face communication such as
telephone• Care Plan progress reviews• The potential to identify escalating conditions before an emergency event
occurs• Improved quality of health by consistent monitoring
50
CCM BENEFITS TO THE HEALTH CENTERHealth Centers will also benefit from participating in the program:• Activities are in line with Patient Centered Medical Home and UDS Measure
Quality Improvement initiatives.• Health Centers will receive payment for activities that are already taking
place• Provides level of accountability for follow-up on chronic care patients• Will prepare the Health Center for billing CCM services to Commercial Payers
as available.
51
CCM RESOURCESCCM Fact Sheet – All Providers ***** Good source of information****• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdfCMS Care Management Webpage• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/Care-Management.htmlCCM Services Changes for 2017-Medicare Learning Network• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2017.pdf
52
CCM RESOURCESMLN Matters – CCM Services for FQHCs and RHCs - MM9234 Revised• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/Downloads/MM9234.pdfCCM FAQs for FQHCs as of February 19, 2016• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdfCCM FAQs as of January 18, 2017 – All Providers• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf
53
APCA RESOURCES• APCA Training & Technical Assistance Staff
• Patty Linduska [email protected]• Penney Benson [email protected]• Lesley de Jaray [email protected]• Marie Jackman [email protected]• Suzanne Niemi [email protected]• Tara Ferguson [email protected]• Tom Taylor [email protected]• Bree Villar [email protected]
907-929-2722
54