Maximize Your Billings in Hospice and Palliative Care

1. Maximize Your Billings in Hospice and Palliative Care

2. Disclaimer • The information contained in this presentation is thought to be as accurate and up-to-date as possible as of the time the slides were created • CMS and other payors may change their policies, and their interpretation, frequently and unpredictably • Ultimate responsibility for decisions on coding and billing for services lies with the provider • Check with your Medicare Administrator Contractor for specific questions; especially with the new codes • Reimbursement based on 2019 NC rates

3. Learning Objectives • Discuss the elements required to meet certain Evaluation/Management Codes • Understand Advance Care Planning Codes • Discuss new codes for 2017-2019 and changes to existing codes • Develop a sense of billings/month/year • Develop a quality improvement plan to develop processes for implementation

4. Palliative Care Provider Billing • All billings → Medicare Part B • Billings paid based on physician fee schedule • Medicare pays 80% of allowable • Must show additional 20% billed to patient or insurance/Medicaid • NP/PA receive 85% of physician rate • Can bill as attending or consulting • Paid by the MACs (Medicare Administrator Contractor)

5. Coding is determined by… • Who are you? • Who is the patient? • Where is the patient? • Time or complexity? • Nuances to our field

6. General Guidelines • Proper Documentation Includes • Care Setting • Reason for Visit • Relevant history, physical, diagnostic labs • Clinical diagnosis and assessment • Plan of care • Date and legible identity of provider

7. Evaluation and Management (E/M) Codes • Determined by: • Patient type • Patient care setting • Level of E/M service billed

8. Patient Care Setting/Type • Inpatient Skilled Nursing Home/ Hospital/GIP Hospice: Initial vs. Subsequent • Outpatient ALF/Domiciliary/Home/Routine care Hospice: New vs. Established

9. Patient Type • New – patient has not been seen by the physician or the physicians in the same sub specialty group within the past 3 years. • Established – patient has received face to face service from the physician or member of the same sub specialty group within 3 years. Example: Patient discharged from PC seen 2 years later in the clinic setting – established patient

10. Consulting Codes • No longer recognized by CMS • Can use with insurers so need to understand when to use • Usually pay at higher rate • 99241-99245 • 99251-99255

11. Types of Coding • There are two methods for determining CPT Levels • Intensity (Component or Element coding) • Time Intensity trumps time!

12. Intensity • If you complete a complex visit and fulfill/exceed all the key components in less than the typical time – you still bill at the higher code. • Example - Subsequent hospital care • 99232 typically 25 minutes • 99233 typically 35 minutes I meet the key components for a 99233 in 20 minutes so I bill the 99233.

13. Intensity vs Time • How should you bill? • General rule of thumb • 75-85% intensity, 15-25% time • May somewhat depend on practice setting and # of family meetings conducted

14. Intensity vs Time • Need to understand both well • Common mistake is to just bill on time • When >50% time is spent in coordination and counseling, time code should be used. (face to face time in outpatient setting/face to face + floor time in inpatient unit)

15. Evaluation & Management Codes First, determine which CPT E&M code to use Location of the patient • New vs. Established (outpatient) • Initial vs. Subsequent (inpatient) Then choose right “level” of service Most often at levels 3, 4 or 5 in our world Based on documentation of Key Components: • History • Exam, and • Medical decision making OR Time = counseling/coordination of care

16. Billing by Intensity Key elements in selection of level • History • Problem focused • Expanded problem focused • Detailed • Comprehensive • Physical – same as above • Medical decision making • Straightforward, Low, Moderate, High

17. History – Key Component I To qualify for a given level of history, all 3 elements in the history table must be met.

18. Physical Exam - Key Component II1995 Guidelines Comprehensive: Gen’l multi-system (8+ OS) or complete single system organ system exam. • Organ Systems (12) • Constitutional • Eyes • Ears, Nose, Mouth, Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Skin • Neurologic • Psychiatric • Hematologic/lymphatic/immunologic • Body Areas: (10) • Head, including face • Neck • Chest, incl. breasts & axillae • Abdomen • Genitalia, groin, buttocks • Back, incl. spine • Each extremity

19. Physical Exam * Check with MAC – Detailed requirements may differ

20. Complexity of Medical Decision Making – Key Component III Complexity of Medical Decision-Making: • Data ordered or reviewed • Diagnosis and Management • Risk of significant complications, morbidity and mortality

21. TABLE OF THE RISK OF COMPLICATIONS, MORBIDITY AND MORTALITY One criteria must be met or exceeded.

22. Coding Using Components History + Examination + Complexity of Medical Decision-Making = the E&M Level

23. Coding Pearls • All subsequent and established visits except office/clinic visits • History, physical & medical decision making - only need 2 out of 3 key components to bill for a particular level of care • HPI – all subsequent visits only need interval history (no need for PMH, SH, FH) • The most important component is medical complexity – assessment and plan, so have thorough documentation in this section

24. Prolonged Service Codes • Inpatient – 99356 • Use for first 30 min over time threshold (60 min code) • Direct face to face time • Ex: 99223 (70 min) 99356 (100 min) • Each additional 30 – 99357 (145 min) • Outpatient – 99354 • Companion code to E/M • Direct face to face time • Each additional 30 min 99355 • Ex: 99350 (60) 99354 (90) 99355(135)

25. Prolonged Service Codes • Used when a physician provides prolonged service involving direct patient contact that is beyond the usual service (typical time) in either the inpatient or outpatient setting • CPT book Direct – includes F2F and Floor time in the hospital and just F2F time in the outpatient setting (including NH), however Medicare requires inpatient F2F • The prolonged time does not have to be continuous, but in-out times must be recorded • Each code is reported separately in addition to appropriate E/M service code • 99356, 99354 – 60 min beyond usual time – 30 min threshold • 99357, 99355- 30 min beyond initial code – 15 min threshold

26. Prolonged Service Codes • Documentation should include: • Start and end time of the visit • Date of visit • Duration of visit • Content of visit • Documentation to support rendering provider furnished direct F2F time

27. 2017 - Non F2F Prolonged Service Codes • 99358 – prolonged E/M service before and/or after direct patient care – first hour* • 99359 – prolonged E/M services before and/or after direct patient care – each add 30 min • Palliative Care Only!! (not Part A) “These codes would provide a means to recognize the additional resource costs of physicians and other billing practitioners, when they spend an extraordinary amount of time outside of an E/M visit performing work that is related to that visit and does not involve direct patient contact (such as extensive medical record review, review of diagnostic test results or other ongoing care management work.”) * 31 minutes you can bill 99358, 76 min for both codes

28. New Non F2F Prolonged Service Codes • Must be directly related to a specific F2F visit that was provided on same or different day • Time must be performed by the billing provider • Time thresholds much be documented • Mid-point needs to be passed to bill • Cannot be billed during complex CCM or TCM codes

29. Reimbursement • 99358 – $109.71 • 99359 - $52.76

30. Scenario 1 68 yo WM hospitalized for exacerbation of COPD with underlying pneumonia. An initial patient comprehensive history & physical, with high MDM is performed. Later in the day, the physician spends 35 minutes reviewing the diagnostic tests and, discusses the case with the hospitalist and intensivist. What is the correct CPT codes for both of these visits which occurred on the same day?

31. Scenario 1 • 99223 – comprehensive H&P, High MDM • 99358 – non F2F prolonged visit code Reimbursement • Day 1 ~ 195 + 110 + = $305

32. Scenario 2 83 yo WF with metastatic colon cancer and mild dementia who is being transferred from the SNF back to the home setting. Palliative Care PA performs established visit with comprehensive history, PE and complex MDM. After seeing the patient, the PA calls the PCP with an update and medication change, followed by discussion with the SW on resource needs in the home. Called daughter and spoke for 35 min. He spends a total of 76 min on these calls and care coordination. • What is the correct CPT codes for these visits?

33. Scenario 2 • 99350 - established home visit • 99358 – non F2F prolonged service code • 99359 – add on to above for non F2F time Reimbursement • Code ~$175 +$110 +$53 = $338 • $350*.85=$287 (PA rate)

34. Distinguish Elements for Time Based Billing

35. The 50% Rule • When these medically necessary activities and/or coordination of care constitute more than 50% of the physician/ patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility) time may be considered the key or controlling factor to qualify for a particular level of E/M service. This includes time spent with those individuals who have assumed responsibility for the care of the patient or decision making, regardless of whether they are family members (e.g., child’s parents, foster parents, person acting in locum parentis, legal guardian). AMA Principles of CPT coding, Rev Edition; 2010

36. Time-Based Coding - Outpatient Face to Face Time for office and other outpatient settings – face-to-face time is defined as only that time which the physician spends face to face with the patient and/or family. Therefore, Non face-to-face time (pre- and post-encounter time) is NOT included in the timecomponent for outpatient work (assumed to be included in the CPT level).

37. Billing by Time Document rationale for using time • Diagnostic results, impressions, and/or recommended diagnostic studies • Prognosis • Risks and benefits of management or treatment choices • Instructions for management (treatment and/or follow-up) • Importance of compliance with chosen management (treatment) options • Treatments initiated or adjusted • Risk factor reduction • Patient and family education Must document the actual time (minutes) and include the notation, “more than 50% of the time was spent in counseling and coordination of care for…...”

38. Questions? • Billing by intensity or time? • Prolonged service codes • Non F2F prolonged service codes

39. Understanding Advance Care Planning Codes and When to Use

40. Only 4 in 10 Americans ≥ 65 years old have advance directives 89% patients feel doctors should discuss Advance Care Planning, however for those ≥ 65 years old only 17% state they have had a conversation with their physician 90% Americans prefer to die at home, yet only a third of all deaths occur in this setting 25% total Medicare spending occurs in the last year of life 10 FAQ’s: Medicare’s Role in End-of-Life, Nov 2015, Kaiser Foundation Fact Sheet Rationale

41. What Constitutes Advance Care Planning? • Understanding health care options that are available for end-of-life care • Deciding what treatments align with patient’s goals • Sharing personal values and goals of care • May include filling out/discussion of advance directives written instructions to help guide care, include living wills, health care power of attorney, and many of the state directives documents • No limit of number of Advance Care Planning codes/beneficiary

42. Who Qualifies for Advance Care Planning Services? • Individuals with end-stage chronic illnesses • Individuals facing emergent and high-risk surgeries, or who experience sudden event • Individuals with dementia or mental illnesses • Individuals who lack decision making capacity • Advance Care Planning codes may be used with a wellness visit

43. Physician or Non-Physician Practitioner (QHP)* Incident to Rules requirements met Must be Qualified Clinical staff Under Direct supervision of Physician or Non-Physician Practitioner Social Worker, Registered Nurse, Chaplain Other clinical staff – Psychologists, Case Managers Billed under provider’s National Provider Identifier (NPI) number *QHP (Qualified Health Professional) applicable state law and scope of practice requirements must be met Who is Qualified to Bill?

44. “Incident to” Requirements • Physician or Non-Physician Practitioner performs initial service • Provider directly supervises and must be present • Manage, participate and meaningful contribution by provider • Incident to applies to office/clinic setting and rural home setting where no home health agency is available • Not hospital/nursing home setting

45. Documentation Required • CMS did not specify “standards or requirements” for billing codes, however must demonstrate • Who is the supervising physician • With whom the conversation occurred • Where the service is provided • Contents of the conversation that occurred • Patient/surrogate acknowledges Advance Care Planning service • Number of minutes spent (Time Based Codes)

46. Frequently Asked Questions • Does the patient need to be present? No, can be with surrogate • Can you provide telephonically? No, requires face-to-face visit • Can more than one provider bill? Yes • Is there a limit to the physician specialty? No • Is there a limit to the number of codes billed? No • Can Advance Care Planning codes be billed at same time of Transitional Care Health Management and Chronic Care Management codes? Yes • Can Advance Care Planning codes be be billed together with routine office visit, hospital visit and nursing home visit E/M charges? Yes

47. Advance Care Planning Codes – Time Based

48. Payment • Medicare Administrative Contractors (MACs) will be responsible for local coverage determination • Currently no National Determination Coverage Policy which gives time for implementation and experience on use of code • 20% co-pay by secondary insurer or patient • For primary care physicians can be an add-on to an Annual Wellness Visit with modifier 33 (in this case no 20% co-pay)

49. Develop a Process • Train appropriate personnel • Develop a standardized process/template • Identify supervising provider • Develop internal auditing system • Track number month/provide

50. Scenario 1 74 year old male with advanced heart disease admitted to the hospital with exacerbation of congestive heart failure. Palliative Care consult requested for dyspnea management and goals of care. Physician completes an initial palliative care consult with recommendations for dyspnea management and advance directives. The billing is based on a comprehensive history and physical with high medical decision making (Incidentally it takes the provider 50 minutes). In addition, clinician discussed what matters most to this patient, and a Do Not Resuscitate (DNR) order is placed in the chart. What is the correct CPT code for this encounter?