ICD-10 clarification from CMS

Here is the link to the CMS FAQ document about specificity and ICD-10.  They clarified that when they said “family” they meant “category” because ICD-10 doesn’t use the term family in coding. (I theorized that if the code was in a page or two of the right code it would be okay, but that’s not what they meant, was it?)  Just a reminder, we use diagnosis coding for two reasons on a claim form.  The first is to establish the medical necessity to get a claim paid.  The second is to tell the payer how sick the patient is, and the acuity of our entire population of patients.  This is important for risk based contracts and ACOs. Even an unspecified code establishes the medical necessity for an office visit, but that doesn’t mean you should use it.  You should report the condition you are treating specifically.  And, if the service you are performing has a Medicare LCD or NCD, or a private payer coverage policy, you will need a specific, covered indication.

As for private payers, who knows?

ICD-10: AMA and CMS come to terms

CMS and the AMA have agreed to offer physician practices a grace period on code specificity of ICD-10 for the first year.  The link to the announcement from the AMA is below, and you’ll notice it mentions “family” of codes.  ICD-10 is divided into categories and subcategories.  I’m not sure how the CMS Contractors will interpret “family.”

If I see any clarification or wise words from other consultants, I’ll add them here.


CMS resources on CCM

Two links I thought you might find helpful.



We appreciate the detail from CMS on chronic care management.

HCPCS modifiers X{EPSU}

April 14, 2015 CMS held an Open Door Forum. The chief medical officer of Program Integrity said this:
CMS released CR8864 describing four new modifiers, a subset of modifier 59 last fall. MedLearn Matters articles followed. CMS stated that further information would be forthcoming in the months and years ahead, and that groups could continue to use modifier 59. As of this date, CMS is still developing these instructions and has no stated time frame as to when they will release them.

CMS’s advice in this call is that there is no reason for not continuing to use modifier 59, and no advantage to using the new modifiers. It continues to be acceptable to use modifier 59.

My advice based on this CMS Open Door Forum: ignore the new -X {EPSU} modifiers until we have specific CMS instructions.

What’s the RAC up to these days?

When you look at the list of topics that the RAC is investigating in Region A, you’ll see that the majority of them relate to inpatient and outpatient services. This makes sense, when you consider that the RACs arcade percentage of the money that they recover. A larger bill means a larger percentage of the returned to the RAC. But there are some areas of concern for physicians in the list.

Infusions, injections, and medications are on the list for both outpatient facilities and physician services. The infusion codes are not new, but they can be confusing. If your practice is doing anything but just an IM injection, be sure to review the rules for infusions. Also, medications have HCPCS codes that define what one unit of the medication is. Set up an alert for an unusual number of units being billed for any medication. There is a long list of medications on the RAC list, and practices that provide infusions should look at this list.

Evaluation and management services appear on the RAC list. These include some automated reviews to be sure that a new patient visit is not being billed and paid when it should be an established patient visit, and that only one E/M service is billed and paid by anyone physician on a calendar date. Using an incorrect place of service continues to be a concern, because services are paid in a variable rate based on place of service. Global services are on the list including pre-and postop visits in the global. Observation admissions and discharge on the same calendar date and observations of less then 8 hours are being reviewed, as are I hope the coach starts today annual wellness visits and allergy services on the same day as an E/M visit.

There are some perennial favorites of course. These include: billing for an add-on code without a primary procedure; reporting services for a patient who is dead; duplicate billings; diagnostic colonoscopy; incorrect use of the bilateral modifier; and therapy claims that are over the maximum allowance for the year. Cardiac monitoring, IMRT, and MOHs surgery make the list along with diagnostic tests including MRA, nerve conduction, EKG, MRI, CT scans and chest x-rays for reasons that are not medically necessary.

When I was speaking with a group of surgeons recently I joked that the way to reduce the risk of billing Medicare to zero was not to bill Medicare. Of course, surgeons know about risk. The correct response is to look at the list and identify services on the list that your practice performs. Then, review the coding rules and reimbursement policies including national and local coverage determinations for those services that you perform frequently. Volume increases risk. If there’s a service on the list you perform once a month you’re at lower risk than if it there’s a service that you perform daily. Start with high-volume services and services with high payment.

Getting paid for coordinating care – what does the primary care provider need to do?

by Narath Carlile MD MPH, Betsy Nicoletti

With the 2015 Final Physician Fee Schedule released on Halloween (they seem to love releasing rules on holidays), CMS has introduced non-visit-based payment for chronic care management (CCM). Despite its modest potential rate (0.61 RVUs, or approximately $40 per patient in a calendar month), this structural shift is arguably “the most important broadly applicable change it has made to primary care payment to date.”

We all know that patients with comorbid conditions can’t and don’t get all the care they need in a 30 minute office visit. Finally, physicians can get paid for the coordination work between visits. Here’s how to make it a reality.
What is it?
The new CPT code (99490) allows physicians to bill for 20 or more minutes that their staff spends on non-visit-based care coordination activities each month for their Medicare patients.

So what?
Quality care requires a lot of coordination work between visits, and usually this responsibility falls on the primary care provider. Since coordination is not a visit or procedure, it has not been reimbursed in the past. Many providers, of course, already coordinate their patients’ care because it is the right and necessary thing to do for positive outcomes—however, it comes at a cost to their practice. The new CPT code can help to offset some of that cost. Now, reimbursement is in-line with realistic workflow and quality.

The bottom line: “A physician caring for 200 qualifying patients could see additional revenue of roughly $100,000 annually.”

How is it done?
In order to bill for this code the following conditions must apply to the patient:
● Patient requires at least 20 minutes per calendar month of clinical staff time coordinating care or communicating with the patient (under general—not direct—supervision)
● Patient suffers from 2+ chronic conditions expected to last at least 12 months or until patient’s death
● The chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
Additionally, the practice must meet the following requirements:
● Use a certified EHR (which includes 2011 or 2014 certifications that meet the core technology requirements) (Final Rule page 474)
● Offer 24/7 access to clinicians (who have access to the care plan) to handle urgent care needs
● Maintain a designated practitioner for each patient
● Regarding the care plan:
○ The physician must collaborate with the patient to develop a comprehensive care plan that is accessible to the care team 24/7 — however, this does not have to be created or transmitted by the EHR, and could be fulfilled more effectively by a platform that is designed to create and share a care plan amongst the whole team caring for a patient
○ The electronic care plan should facilitate caring for the patient during transitions
○ Notably, it must be possible to share this care plan digitally with the patient and external providers (including community providers) and the patient needs to have web based access to this as well
● Care management includes assessment of the patient’s medical, functional and psychosocial needs.
And the patient will need to do the following:
● Consent (annually) to you providing CCM services
● Pay the copay for each month you bill for CCM services (approx $8) (of note many patients will have secondary insurance which will cover this)
Really, how is it done?
For many PCMH’s (or practices in the process of becoming one), most of the requirements can be met with the simple addition of an electronic team-based care-planning tool like ACT.md.

Many foresee the major stumbling block being tracking the time spent on between-visit work across multiple team members and easily reporting this so appropriate billing can be done. Some electronic platforms for team-based care coordination like ACT.md can make this very easy.

Is anyone really taking this on in January?
Yes, and you should take advantage of immediately! We are working with practices who have successfully billed for Transitional Care Management (TCM), and we have identified the tools and processes necessary for practices to address the requirements outlined. We are also starting to test the waters of reimbursement with PCMH’s and ACO’s for all the work they already do.

To claim your coordination reimbursement, we recommend you do these things immediately: First, identify patients that qualify. Second, educate patients and obtain their consent in advance. Third, take another look at your EMR’s functionality to see what it can already do to support this. Fourth, determine how to create a patient-centered care plan based on your usual procedures. Last, identify a way for the entire care team, including the patient and caregiver, to communicate and execute effectively on that care plan.

According to a CMS provider call, RHCs and FQHCs may not report CCM. Also, CCM must be initiated at an AWV, Welcome to Medicare visit or “comprehensive” E/M. The plan may have been developed prior to 2015.

Chronic Care Management: new CPT and CMS benefit code for 2015


In the 2015 Final Physician Fee Schedule released on Halloween (CMS loves holiday releases of rules) CMS continues to state its support for primary care. One of the methods: a new benefit, chronic care management (CCM) for which they are proposing a rate of about $40 for 20 minutes or more of this non-face-to-face service during a calendar month. We knew about this from the proposed rule but were in wait and see mode until the final rule came out.

Here’s a surprise! CMS is going to use a CPT code instead of developing a HCPCS code to describe the service. In the proposed rule they stated their intention of developing a HCPCS code but they’ve changed their minds. This means that practices can learn about this code right in a resource that is sitting on their shelves. I hope everyone reading this has their 2015 CPT code on the desk right now.

The new CPT code is 99490: chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following elements:
• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
• chronic conditions placed the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
• comprehensive Care plan established, implemented, revised, or monitored.

There is an additional editorial note stating “chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately.”

CMS will not use the CPT codes for complex chronic care coordination services 99487—99489. Those will continue to have a bundled status indicator.

In order to be eligible the patient must have two or more significant chronic problems, expected to last at least 12 months or be life long conditions. They must be the type of conditions that pose a real risk to the patient’s health and well-being. The practice must implement a care plan that addresses the patient’s conditions and a clinical staff member must spend 20 minutes during a calendar coordinating care and communicating with the patient. The practice must use a certified EHR. The physician develops a care plan, and everyone who has contact with the patient must have access to the electronic care plan. A copy of the care plan is provided to the patient, electronically or on paper. The electronic record must include a full list of problems and medications and should facilitate caring for the patient during care transitions. Medication reconciliation is required as part of the service. The patient must have access to the practice 24 hours a day, 7 days a week. One provider must be designated for continuity of care. Care management includes assessment of the patient’s medical, functional and psychosocial needs.The practice must create a patient-centered care plan, manage care transitions, and coordinate with home and community services.

Informed consent is required before starting the service. The practice must inform the patient that they will provide this service and get written consent from the patient to do so and to share information with other providers. The practice must also inform that patient that they can revoke this consent and stop receiving CCM services at any time. Document these communications in the record, and give the patient a written or electronic copy of the care plan. The co-pay and deductible are not waived for this service, but will be patient due.

CMS is proposing general, not direct, supervision of the clinical staff who perform these services. Nursing staff after hours or during normal business hours may perform these coordination services even if the physician or billing NPP is not in the office

It looks like a lot of work to me for $40.00. The practice may only report this service during the month in which the clinical staff has 20 minutes of non-face-to-face time with the patient. If the practice is already providing these services as part of a patient centered medical home, the service will be easier to provide and may not represent significant additional cost. The payment may support the additional infrastructure needed to manage the care of these patients.

If you have your 2015 copy of the CPT book—and, again, I hope you do– you can read for yourself in more detail what the billing rules are. I am summarizing these but it is no substitute for reading them yourself. First, both CPT and CMS state that clinical staff should be doing the work. Also, a practice may not count any clinical staff time on a day when the physician or qualified healthcare professional (NP/PA) has an evaluation and management service with the patient. However, E/M services may be reported during the same calendar month the chronic care management is provided. There is a list of services in the CPT book that are bundled into chronic care management. These include care plan oversight and transitional care management, amongst other codes. The surgeon may not perform chronic care management during the postop period.

If your practice is already a patient centered medical home or you are already providing case management for a group of chronically ill patients, you are ready to begin performing chronic care management. However, if you are not already providing the services it is unlikely that you will be able to do these starting January 1. It requires an infrastructure within the practice to provide the services. Also, you will need to have an evaluation and management service with the patient to explain the service, sign the informed consent, and develop the care plan. This calls for gradually rolling out chronic care management services not immediately reporting them on all patients who will be eligible. Remember this is not a per member per month benefit– just because you provide the service one month does not mean you can provide the service the next month. The clinical staff must spend at least 20 minutes providing these coordination and care management services in order to report them. Most practices don’t have a template or form setup for this. Groups will need to think about how and where this information is being documented before rushing to bill for this service.