Improve Outcomes & Revenue ANNUAL WELLNESS VISITS & CHRONIC CARE MANAGMENT

Agenda Review of CMS Programs: AWV & CCM Review of CPT/HCPCS Codes and Reimbursements Current Adoption Rates Initial Patient Outcome Improvement

Annual Wellness Visit This is a preventive service for Medicare patients to perform a holistic patient assessment, document a preventive services schedule, and outline the annual treatment plan for the patient. Eligibility: Medicare Patient Not in their first 12 months No IPPE or AWV in last 12 months

Codes Initial AWV G0438 Subsequent AWV G0439 Initial AWVs are performed once per lifetime Use HETS/IVR to obtain AWV eligibility Subsequent AWV G0439 Subsequent is defined as any AWV performed after the initial Subsequent AWVs can be performed once per year Preventive Services can also be performed Ex: Tobacco Screening Ex: Advance Care Planning Coinsurance is waived when billed with an AWV Ex: Depression Screening For the initial AWV this service is included in the reimbursement

In Clinic Service Elements The ABCs of Annual Wellness Visits Acquire Beneficiary Information Review the beneficiary's medical, family, and social history* Review the beneficiary's potential risk factors for depression, including current or past experiences with depression or other mood disorders* Review the beneficiary's functional ability and level of safety* Begin Assessment Assess the patient: HT, WT, BMI, BP & any other routine measures as deemed appropriate Detect any cognitive impairment the beneficiary may have Counsel Beneficiary Establish a written screening schedule for the patient to use as a 5-10 year checklist* Establish a list of risk factors and conditions for which primary, secondary, tertiary interventions are recommended or underway for the beneficiary* Furnish personalized health advice to the beneficiary and a referral, as appropriate, to health education or preventive counseling services or programs* The services to perform in-clinic are well supported by the previous slide. Each item listed here is required by CMS. Each item listed with an asterisk is one that will be prepared in advance by H3C.

Reimbursements & Requirements Requirements include: Health Risk Assessment Current List of Providers Establish Patient Histories Review & Document Risk Factors Review ADLs & Safety Assess Vitals Assess Cognition Draft Screening Schedule Provide Advice & Education Provide Care Coordination Rate by Location Initial AWV Subsequent AWV National Rates $175.32 $119.16 Missouri – KC Metro $172.70 $117.14 Missouri – St. Louis Metro $172.26 $116.83 Missouri – The Rest of MO $164.03 $110.70 Missouri – RHC AIR $83.45

Chronic Care Management This is a care coordination program created by Medicare to improve the outcomes of patients with multiple chronic conditions. Eligibility: Patient has been seen in last 12 months Patient has 2+ chronic conditions Patient has Medicare Patient has consented to participate

History of CCM for FQHCs and RHCs 2016 2017 2018 CCM Codes Released Direct Supervision Required Complex CCM is not reimbursed CCM Codes Remain General Supervision Allowed Complex CCM is not reimbursed CCM Codes Replaced by GCM General Supervision Allowed Complex CCM is a factor of reimbursement 2016 payment (CPT Code 99490) – $40.82 2017 payment (CPT Code 99490) – $42.71 2018 payment (Code G0511) – $62.28

Care Management Codes Chronic Care Management 99490 Complex Chronic Care Management 99487 Requires medical decision-making Complex Chronic Care Management (Add-On) 99489 Cannot be added onto 99490 Care Planning G0506 Is only intended to be billed once at initiation of CCM RHC General Care Management G0511

Quick Facts HCPCS Code G0511 Reimbursement is calculated based upon the average of the national rates for: Chronic Care Management (99490) Complex Chronic Care Management (99487) Behavioral Health Integration (CPT 99484) Billing for the 99490, 99487, or 99484 as an FQHC or RHC after 1/1/18 results in denials

Chronic Care Management (CCM) CCM Requirements 20 Minutes 2+ Chronic Conditions 24/7 Access to Care CEHRT Platform Chronic Care Management (CCM) The CCM Care Plan must be signed off by a provider. The rest of the CCM work can be performed by clinical staff under the general supervision of the provider. Appropriate escalation policies should be put into place. Items to include: Medication Reconciliation Review of Histories Collaboration with Specialists Review of Treatment Goals Baseline Vitals Assessment

CCM & GCM Reimbursements Rate by Location CCM Complex CCM Complex CCM Add On Care Planning General Care Management G0511 National Rates $42.84 $94.68 $47.16 $64.44 n/a Missouri – KC Metro $42.23 $92.75 $42.60 $63.45 Missouri – St. Louis Metro $42.12 $92.48 $46.07 $63.28 Missouri – The Rest of MO $40.17 $86.92 $43.30 $60.18 Missouri – RHC  $62.28 Coinsurance: G0511:  DOS is a calendar month Applies Can be a stand alone claim Revenue code 052x CANNOT be waived CANNOT be billed with TCM services 20% of charges Is NOT factored into the RHC AIR

The Cost of Chronic Disease Between 2016 – 2030 the estimated cost of Chronic Disease is $42 Trillion. Only 5% of people account for 50% of that overall healthcare spend. Every 30 seconds, a patient has a limb amputated due to untreated or exacerbated diabetes. Patients with chronic conditions account for 81% of overall U.S. hospitalizations The partnership to fight chronic disease estimates that 16 million lives can be saved over the next 12 years with improved chronic disease management. Chronic disease accounts for 7 of every 10 deaths in the U.S.

Across the Nation: CCM Participants Total Medicare Beneficiaries: 55,550,400 Average 64% Eligible: 35,552,256 Actual CCM Services: 684,000 1.9% of eligible patients Here you can see that of 55M beneficiaries over 35M on average were eligible for CCM. Services were performed for just over half a million patients. To put that in perspective that’s the equivalent of treating less than 2 of every 100 patients. This is 2015 data so the number of beneficiaries and the number that are CCM eligible have actually increased to 58 Million beneficiaries and 70% eligible for CCM. However, as retrospective data goes, we have the most on 2015.

The Nation vs. Missouri 67% The Average for Missouri The Nation AWVs Performed 17% of eligible 18% of eligible Diabetic Screenings 3% of eligible 5% of eligible 67% of Missouri Medicare patients have two or more chronic conditions. On average they cost $4,421 per patient per year due to lack of management. For every 100 patients discharged after an AMI, 15 are readmitted. For every 100 patients discharged after heart failure, 20 are readmitted. In rural hospitals these numbers are usually higher, one rural hospital in Missouri averages 74 readmissions for every 100 discharged heart failure patients.

Chronic Care Management Study YOUR NEEDS AS AN ACO

Patient Outcome Data

CMS Study Findings Patient satisfaction higher Improved Adherence to recommended therapies Improved clinician efficiency Decreased hospitalizations and ED visits Enhanced patient access through CM More frequent condition management b/n visits Improved Med Reconciliation

AWV Outcome Data Large enterprise data analytics organization Represent over 200 ACOs and Hospitals “Overall we have seen a 44% reduction in cost for patients who’ve had an AWV versus patient’s who have not across our shared risk and/or shared savings participants”

AWV Reference Tools The ABCs of The AWV CDC Advisory Committee (ACIP) A Framework for HRAs Medicare Preventive Services Tool US Preventive Services Taskforce CMS MAC Contractor Map

Thank You Taya Moheiser, CMPE Advisory Services Director Taya Thank You Taya Moheiser, CMPE Advisory Services Director Taya.Moheiser@h3ci.com Elizabeth Chandler Director, Strategic Accounts Elizabeth.Chandler@h3ci.com

Resources The ABCs of the Annual Wellness Visit (AWV) Rural Health Clinic (RHC) Preventive Services Chart Update to Rural Health Clinic (RHC) All Inclusive Rate (AIR) Payment Limit for Calendar Year (CY) 2018 The Medicare Physician Fee Schedule Mathematica Report: Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Service: Final Report 11/2/2017 Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)