2016 Billing and Coding Collaborative- Webinar One Michigan Primary Care Transformation Project March 29, 2016

AGENDA Welcome/Introductions 2016 Billing and Coding Collaborative Approach BCBSM and BCN Tips CMS Key Codes Review Multipayer Grid ( under “resources” in the billing and coding dropdown) Bubble Charts: A Look at the Depth and Breadth of Coding

Billing and Coding Collaborative! Welcome to the 2016 MiPCT All are invited (whether interested in practice learning credits or not) Additional sessions (tentatively May/June, August/Sept, November) Practice Learning Credits Option ▫Four credits possible ▫PO or practice may participate

BCBSM & BCN Tips Effective January 1, 2016, BCBSM now waives the cost share for ALL MiPCT/PDCM services including those members with a High Deductible Health Plan with a Health Savings Account. The expectation is that a G9001 is completed. Always verify the patient has an active BCBSM or BCN contract. –For BCN the patient list is your determining factor for MiPCT eligibility. –For BCBSM you also need to check webDENIS or PARS for MiPCT/PDCM contract eligibility. Use the practices existing processes to check eligibility. Some groups reject obesity and/or mental health diagnoses. Questions: log an issue on the PGIP Collaboration site or send an to

CMS Key Care Mgt Code Review TCM: Transitional Care Mgt (99495,99496) CCM: Chronic Care Mgt Services (99490) ACP: Advance Care Planning (99497, 99498)

What is Transitional Care Management (TCM)? TCM includes services provided to a patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions of care from an inpatient hospital setting, partial hospital, observation status in a hospital or skilled nursing facility, to the patient’s community setting (home, assisted living, etc.)

TCM Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit within 14 calendar days of discharge

TCM Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit within 7 calendar days of discharge

Transitional Care Management (99495 and 99496) ▫Now allows submission of claim when the face-to- face visit is completed 9 The Final PFS (Issued 10/30/15)- Implications for the MiPCT

Can MiPCT Practices bill Centers for Medicare & Medicaid Services (CMS) Transitional Care Management (TCM) codes? Medicare and Medicaid - MiPCT practices can bill TCM 99495, for Medicare and Medicaid  for patients attributed to the PCP in the practice and patient has the health plan benefit Reference: Fact-Sheet-ICN pdfhttps:// Fact-Sheet-ICN pdf

Chronic Care Management Services(CCM) code CCM payment was announced by CMS 2015 – Medicare Physician Fee Schedule Final Rule Five capabilities CMS requires a provider to have to bill for CCM ▫Use a certified EHR for specified purposes, ▫Maintain an electronic care plan, ▫Ensure beneficiary access to care, ▫Facilitation TOC and, ▫Coordinate care

Chronic Care Management Services(CCM) code CCM specifies: Beneficiary – diagnosis of 2 or more chronic conditions expected to persist at least 12 months ▫Places the individual at significant risk of death, acute exacerbation/decompensation or functional decline

Effective Date of Payment and Rate ▫January 1, 2015 ▫$41.92 monthly (expectation of at least 20 minutes of clinical services per month) Which Medicare patients are eligible? ▫Beneficiaries with 2+ chronic conditions that:  Place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and  For whom care coordination services would be expected to last at least 12 months or until the death of the patient 13 CMS Chronic Care Management

CMS Chronic Care Management Payment ▫24/7 access to health care provider in the practice ▫Continuity of care with a designated provider ▫Systematic assessment of health needs, preventive services, medication reconciliation ▫Creation of a patient-centered care plan document ▫Management of care transitions ▫Coordination with home/community services ▫Secure messaging, internet or other non-face to face communication available ▫Written agreement from beneficiary for CCM services, documented in chart ▫Informing beneficiary that only one practitioner can be paid for these services during the month as well as process for revoking agreement to participate 14 Chronic Care Management Definition

Can MiPCT Practices bill Centers for Medicare & Medicaid Services Chronic Care Management Services(CCM) code? Chronic Care Management Code (CCM) Medicare cannot be billed for CCM if the patient is attributed to your practice (i.e patient is on the MiPCT list) References:

Purpose: To pay for a provider's time discussing patient choices for advance directives and completing necessary forms. Code Detail:  Coverage of first 30 minutes  Additional 30-minute blocks Effective: Beginning 1/1/16, CMS will reimburse CPT codes and Advance Care Planning Codes

Does NOT waive beneficiary copay for discussions (except for discussions at annual wellness visits) Also billable for FQHCs and RHCs Payment estimated at $86 for (initial 30-minutes) and $75 for (subsequent 30 minutes). 17 Advance Care Planning, cont.

MiPCT Multi-Payer Summary Billing Documents

Bubble Charts Data from G and CPT code reports The charts highlight three factors: ▫Breadth (How many members are seen) ▫Depth (How many visits per member) ▫Consistency (Degree to which practices are similar within a PO)

Depth, Breadth and Consistency The charts highlight three factors: ▫Breadth (How many members are seen)  % Eligible Members Engaged in Care Management ▫Depth (How many visits per member)  # Care Management Claims per Engaged Member ▫Consistency (Degree to which practices are similar within a PO)  Standard deviation of breadth calculation above among practices in PO

Breadth Breadth (How many patients are seen)  % Eligible Members Engaged in Care Management  Total Members Engaged in Care Management (since April 2012)/Eligible Members (most recent month)  POs to the right have achieved the most breadth, or have had the largest reach among eligible members

Depth Depth (How many visits per member)  # Care Management Claims per Engaged Member  Total # of Care Management Claims/Eligible Members (most recent month)  POs at the top of the graph have achieved the most depth, or have had the highest number of visits per members

Consistency Consistency (Degree to which practices are similar within a PO)  Standard deviation among all MiPCT practices within the PO  % Eligible Members Engaged in Care Management  Small bubble = more consistent, Large bubble = less consistent  Type of organization will also impact consistency (independent IPA vs. PHO, etc.)

Top 50 th Percentile – % Members Served (Commercial Payer G and CPT Codes) PO # Care Management Claims % of Eligible Members Engaged in Care Management Professional Medical Corporation, PC333431% Saint Mary's PHO92821% Physicians' Organization of Western Michigan361518% Sparrow Physician's Health Network370216% Primary Care Partners, Inc. (Covenant)122216% Upper Peninsula Health Group99013% Medical Network One373612% Mercy Physician Community PHO44612% Oakland Physician Network Services49512% Northern Physician Organization Inc229511% West Michigan Physician's Network228410% Great Lakes OSC56510% CIPA25359% University of Michigan Health System183279% Jackson Health Network1039% Metro Health PHO30118% Oakwood ACO3468% Affinia Health Network Lakeshore54338%

Polling Questions 1) Was this webinar helpful? ▫(Very helpful, somewhat helpful, not helpful) 2) What other topics would you like to see covered in future webinars? 3) Please share your recommendations for improving our 2016 billing and coding collaboratives 29