Monday, December 15, 2014

Medicare Fee-for-Service Update: Chronic Care Management

In the 2015 Medicare Physician Fee Schedule Final Rule, CMS approved Chronic Care Management.  This is not a capitated service, or automatically payable for any patient with 2 or more chronic conditions that are likely to decompensate  and cause hospitalization or death in the next 12 calendar months.

As mentioned, these are not automatic or capitated payments, and there are 5 important capabilities a provider must have in order to bill for these services.   In addition, they must have authorization from the beneficiary to communicate electronically with other providers to coordinate this care.  The beneficiary must be informed they can revoke this authorization at any time.

The five capabilities include: (1) Use a certified EHR for specified purposes in the rule;
(2) Maintain an electronic care plan and provide 24/7 access to it (3) Ensure beneficiary access to care; (4) Facilitate transitions of care; and (5) Coordinate care.

When a provider submits a claim for CCM, the provider is attesting to the fact the provider has met each of these capabilities in full, and there are many provisions to fulfill for each one.

Importantly, only one physician can bill for these services in a calendar month. While there is no speciality requirement, CMS seems to think that the PCP will be the one billing for the CCM. So, what qualifies a beneficiary for this service?

Those qualifications are laid out in CPT code 99487:

Complex chronic care management services, with the following required
• Multiple (two or more) chronic conditions expected to last at least 12
months, or until the death of the patient;
• Chronic conditions place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline;
• Establishment or substantial revision of a comprehensive care plan;
• Moderate or high complexity medical decision making;
• 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

No physician or physician extender (NP, PA, CNS) should bill for Chronic Care Management without reviewing the 14 or so pages dedicated to it in the 2015 Medicare Physician Fee Schedule Final Rule.  If you don’t want to do that, you’ll need to wait for the billing instructions from your Medicare Administrative Contractor to ensure you’re following all the rules. 

While the code itself speaks about “staff time” it also speaks about complex medical decision making—physician staff cannot perform any portion of it that requires medical decision making—this is reserved for clinicians who can make a diagnosis.  So, this is not merely a staff activity.  Medicare envisions this as a component to the overall care of chronically ill patients, and not a replacement to that care.

Friday, November 7, 2014

CMS offers CME/CE Credits for Health Professionals

CMS has announced three new ICD-10 courses on Medscape. If you do not have a Medscape account, you will be prompted to create one the first time you go to the site.

CME credits are available for physicians, and CE credits are available for nurses.  The following videos are available:

Remember that CMS also offers the Road to ICD-10 website:

Wednesday, October 29, 2014

What's New for 2015 and beyond...

Important Encounter Data Reminders and Updates

Remember, effective July 2014, Medicare has implemented the 13 month processing window for timely filing of encounter data.  Encounters older than 13 months will receive an informational edit from CMS—but this will change to a reject, which could happen at any time. Remember, that your encounter must be processed by SCAN first, so it’s important that encounters be received in advance of that 13 month time limit.  We expect to receive notice from CMS prior to them beginning to reject encounters.

Adjustments are not subject to the 13 month window,   but SCAN must submit them to CMS within 30 days of their adjudication.

Encounter Data Processing System

Both the Risk Adjustment Processing System (RAPS) and the Encounter Data Processing System (EDPS) will be used in 2015.  CMS will make an announcement prior to discontinuing RAPS and moving to only EDPS for risk adjustment calculations.

CMS Announcement for new HCPCS modifier codes to replace modifier -59. Effective January 1, 2015. Read the full release HERE.   This information is important for correct submission of encounter data.

Effective: January 1. 2015 there are four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”   Modifier -59 identifies services which normally are considered “bundled” in the main procedure.

Please make sure your billing staffs are aware of the coding modifier changes. The new HCPCS modifiers are collectively referred to as –X {EPSU} modifiers:

• XE- Separate Encounter- A service that is distinct because it occurred during a separate encounter.
• XS- Separate Structure- A service that is distinct because it was performed on a separate organ/structure.
• XP- Separate Practitioner- A service that is distinct because it was performed by a different practitioner.
• XU- Unusual Non-Overlapping Service- The use of a service that is distinct because it does not overlap usual components of the main service.

CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific - X {EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI Procedure-To-Procedure code pair may be identified as payable only with the - XE separate encounter modifier but not the -59 or other - X {EPSU} modifiers. The - X {EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.
CMS recommends the use of the new HCPCS modifiers in place of the -59 modifier whenever possible. SCAN also encourages all physicians, providers and billing staff to familiarize yourselves with these new HCPCS modifiers and implement them into your billing systems as directed by CMS. Effective starting date of service for use of HCPCS modifiers –X {EPSU} is January 1, 2015.

Encounter Data Submission Timetable—The timetable below shows the new submission requirements for Health Plans to CMS.  It also includes the risk score run dates.  The Encounter Data Team will notify you, in advance, when encounters are required to be sent to SCAN:

Risk Score Run
Dates of Service
Deadline for RAPS Submission*

2015 Initial
2014 Final
2015 Mid-Year
2016 Initial
2015 Final

 As we receive new information from CMS, we'll be sure to post it here.

Monday, June 30, 2014

What's New For the rest of 2014 and Beyond?

It seems like Risk Adjustment for Medicare Advantage is ever-evolving.   According to a Final Rule, published by CMS in the Federal Register on May 23, 2014, the one thing we can certainly expect more of is audits.

CMS will be introducing a Recovery Audit Contractor (RAC) for Part C, slated before the end of 2014.  RAC auditors use a combination of methods, including medical record review and automated edits, to identify improper payments.  Currently, there are RAC contractors in Part A, B and D--so the addition of a Part C RAC will mean that all of Medicare is under RAC audits.

We don't yet know what RAC audits for Part C will look like--but if you want to stay ahead of the curve, you should be looking at your data for any anomalies now.  Speaking at an America's Health Insurance Plans conference, Sonja Brown, a health insurance specialist in the Center for Program Integrity in CMS’s Division of Plan Oversight and Accountability,initial areas of review are end-stage renal disease (ESRD), hospice and Medicare as Secondary Payer (MSP).

In addition to the RAC, beginning in 2015, the OIG will be doing their own Risk Adjustment Data Validation Audits (RADV), which we assume will look just like a CMS RADV, but may be more targeted.

This means that with so many audits going on simultaneously, it will be the rare medical group that is not affected.  Medical groups should be doing their own internal chart reviews to determine where more physician education is needed.

We'll continue to keep you up to date on new and changing rules from CMS as we become aware of them.

Wednesday, June 18, 2014

ICD-10 Webcast for Internal Medicine and Family Practice Posted

This morning, CMS posted a new webcast, aimed at primary care physicians on their website:  

An AHIMA-certified coder presents training focused on unique ICD-10 clinical documentation needs and hot topics for each medical specialty. The five webinars will follow the same outline and objectives catering to each medical specialty with specific examples.
  • Physician Perspective/clinical impact of ICD-10
  • Documentation requirements for certain conditions
  • Documentation changes and new concepts
  • Use of “unspecified” in ICD-10

This webcast features Dr. Maggie Gaglione, a board certified internist and bariatrics specialist, a physician in private practice in Virginia.  Per Dr. Gaglione:

“Comprehensive documentation is key to identifying and assigning the best diagnosis code. By doing our part, and focusing on how we document our patients’ condition we put the foundation in place to drive value based quality and improve the health of populations served.”

You can view this webcast here.

Thursday, June 12, 2014

CMS Offers New ICD-10 Content

As part of their ongoing "Road to 10" series, CMS has posted a newly released webcast on ICD-10 documentation and coding concepts for cardiology.  You can access this webcast here, on the webcasts page of The Road to 10: The Small Physician Practice's Guide to ICD-10 website.

An AHIMA-certified coder presents on the webcast, which focuses on unique ICD-10 clinical documentation needs and hot topics for cardiology:

  • • Physician perspective/clinical impact of ICD-10
  • • Documentation requirements for certain conditions
  • • Documentation changes and new concepts
  • • Use of "unspecified" codes in ICD-10

In addition to the newly posted Cardiology webcast, you can find webcasts geared toward Orthopedic Surgery, OB/GYN and Pediatrics.   There will soon be a Family Practice/Internal Medicine webcast as well.  
In addition to these specialty geared webcasts, the website contains a wealth of ICD-10 related information, including a guide to building an action plan, and templates that you can use with that action plan.

We encourage you to visit the website for authoritative information on ICD-10-CM.

Tuesday, February 18, 2014

ICD-10 Rural or Urban; It Impacts All Providers (+playlist)

This CMS video discusses the impact of ICD-10 Implementation on all providers.

For physcians and other treating clinicians, one of the most important considerations is documentation.  If you accurately and concisely document a disease, then you have the best chance of you or your coder finding an appropriate ICD-10 (or ICD-9) code.

I hope this video is helpful.

Thursday, January 23, 2014

Confessions of a Vegetarian Coder—or, why I hate M.E.A.T.!!

First-- I hope I’m not offending anyone.   The spirit of this post is lighthearted, and I’m having a little bit of fun. BUT, I’m also serious about proper coding, and that’s my only intent.  Better documentation and coding helps us all in many ways, and should lead to better and more efficient medical care for the members of our medical groups and health plans. It also affects our reimbursement. Done correctly, though—a wealth of important information is obtained, to help our members to obtain access to excellent treatment programs, that enhance their lives and living.

So, there is NOTHING official about “MEAT”, it’s just a handy acronym that someone thought up one day.   It’s cute.   It sort of addresses what’s needed for ANY diagnosis, not just risk adjustment or so-called “HCC Coding” (which also doesn’t exist).  By law, under HIPAA, what is required for any ICD-9 code is defined by what is in the ICD-9-CM Official Guidelines for Coding and Reporting,  found here ,  and Coding Clinic (see the 2nd paragraph of the guidelines).  You can’t replace 107 pages with 4 letters, two of which mean the same thing!

If you look at MEAT for just a minute, you can see it’s not official, and pretty meaningless:

Monitoring (or Medication)


Assessment;  or


Evaluation and Assessment mean exactly the same thing!  And no “Official Guideline”  for anything, much less something that leads to Federal Government payment, would be complete at 4 letters, 6 if you include the “or”.   

EVERY condition that is submitted as an ICD-9 code has to meet the Official Guidelines.  There’s no exception because something doesn’t risk adjust.  Just writing the word “Stable” does not magically mean you can code something.  Or just because the diagnosis listed under the “Assessment” heading in a chart note doesn’t mean someone assessed it.  What is under that word are conclusions, 90 times out of 100, not an evaluation of the patient or an assessment.   If you look at the word “evaluation” in, it says this:





1 an act or instance of evaluating or appraising.

2. (especially in medicine) a diagnosis or diagnostic study of a physical or mental condition.  (emphasis added)

Here’s where the word “meat” or “substance” comes into play. There really has to be some substance to an evaluation.   Just writing:

Diabetes with neurological manifestations

in a chart note does not mean the doctor evaluated ANYTHING or can code 250.60

First of all ________manifestations isn’t a diagnosis at all. By itself, it means nothing.  No matter what someone from somewhere told you, you cannot just write “stable” or “continue on meds” next to a couple of words and you now have something you can code.  I have seen it fail in CMS RADVs more than once.  And I think that failing something like that is proper.  It never should have been coded in the first place! 

On the other hand, if you can see in that chart note that the  physician did a foot exam, and documented the patients symptoms of burning or tingling in their feet, did a monofilament exam—NOW YOU HAVE SOMETHING!!!!!!!!!

Now he or she can say in the “Assessment” section:

Diabetes with diabetic polyneuropathy.  Patient started on Neurontin, 300 mg, TID

TA DA!! We have something that we can code!!!  YAY!!!!!!!!!!!!!  There is the "meat" that's needed.  An evaluation and/or some indication that the condition was either assessed, being treated (actively) or it has an impact on the treatment of other diseases as the ICD-9 requires.

When people talk about “HCC Coding” being somehow different, there isn’t really a citation they can point to, or an example.   On the other hand, CMS DOES have specific signature requirements for a medical record, but that isn’t a coding issue per se. It is a Medical Record issue.  So, in my diet, I’m a happy omnivore, savoring a juicy steak when I can.  But when it comes to “M.E.A.T.” and coding, I’m a vegetarian coder all the way.
Stacey Hernandez, CCS-P