Preventive Medicine Coding learning how to document/code prevention Steve Adams, MCS, COC, CPC, CPMA, CPC-I, PCS, FCS, COA email: steve.adams@inhealthps.com web: thecodingeducator.com

www.thecodingeducator.com

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending

Discussion Points Transitional Care Management CCM Services Preventive Services IPPE (Welcome to Medicare) AWV – Initial AWV – Subsequent ACP Breast/Pelvic Obtain Pap Smear Tobacco Cessation Counseling Home Health Certification and Recertification Bonus Codes

Transitional Care Management Chronic Care Management

TCMS - New 99495 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 99496 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

TCM Form

Reimbursement of Services CMS has valued the two codes: 99495 at 4.82 (2.11w) RVUs, or about $163 99496 at 6.79 (3.05w) RVUs, or about $230. www.thecodingeducator.com

Medical Assistants

Billing Date

CCM 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 requiring he following: 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; A comprehensive care plan established, implemented, revised, or monitored

Description: The conditions with the highest period prevalence rates are hypertension (57%) and hyperlipidemia (47%). Nearly one-third of the population has been treated for rheumatoid/osteo-arthritis (30%), ischemic heart disease (29%), and diabetes (28%). Technical notes: Period prevalence is calculated for these rates. Beneficiaries with full or nearly full fee-for-service (FFS) coverage during the year who received treatment for the condition within the condition-specified look back period. Chronic conditions have a 1 to 3 year look-back time period. Please refer to the CCW Chronic Condition Categories for algorithm criteria. Denominator is all who were enrolled in Medicare on or after January 1, 2013 and had full or nearly full FFS coverage (i.e., 11 or 12 months of Medicare Part A and B [or coverage until time of death] and one month or less of HMO coverage). Only females are included in the denominator for endometrial and female breast cancer; only males are included for prostate cancer and benign prostatic hyperplasia. Beneficiaries may be counted in more than one chronic condition category. https://www.ccwdata.org/web/guest/medicare-charts/medicare-chronic-condition-charts

CCM CCM will include: Communication with patient, family, community services Collection of outcomes data Education Assessment and Support Facilitating access to care Development of Comprehensive Plan of Care Ongoing review of patient’s status Development, communication and maintenance of a comprehensive care plan

CCM CCM will include: 24/7 access to providers Continuity of care and appointments Timely follow-up from ER or hospital discharge – TCM Services Utilizes an EMR Identify, thru EMR who is eligible have an internal care management process/function whereby a patient identified as meeting the requirements for these services starts receiving them in a timely manner. Use a form and format in the medical record that is standardized within the practice Patient has to agree to receive CCM services

CCM A plan of care must be documented and shared with the patient and/or caregiver. A care plan is based on a physical, mental, cognitive, social, functional, and environmental assessment. It’s a comprehensive plan of care for all health problems. It normally includes: Problem list Expected outcome and prognosis Measurable treatment goals Symptom management Planned interventions Medication management Community/social services ordered How the services of agencies will be connected to he patien Identification of who is responsible for what issues www.thecodingeducator.com

Preventive Medicine www.thecodingeducator.com

Z00.00 – without abnormal findings Z00.01 – with abnormal findings Use the “abnormal findings” when you have a problem that requires a new plan of care – it’s not intended for a routine problem that is stable

Prevention Services CMS has developed separate Level II HCPCS codes for the first annual wellness visit, to be paid at the rate of a level 4 office visit for a new patient (similar to the IPPE), and for the subsequent annual wellness visits, to be paid at the rate of a level 4 office visit for an established patient.

IPPE

IPPE- Welcome to Medicare Review Medical and Social History. Review Risk Factors for Depression and Mood Disorders. Review Functional Ability and Level of Safety. Height, Weight, BP, VA, BMI. End-of-life Planning If Needed Education, Counseling and Referrals Based on Above Education, Counseling, and Referrals for Other Listed Services www.thecodingeducator.com

AWV www.thecodingeducator.com

New AWV Codes G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit); and G0439 (Annual wellness visit; includes a personalized prevention plan of service (PPPS),subsequent visit). We note that practitioners furnishing a preventive medicine E/M service that does not meet the requirements for the IPPE or the AWV would continue to report one of the preventive medicine E/M services CPT codes in the range of 99381 through 99397 as appropriate to the patient's circumstances, and these codes continue to be noncovered by Medicare."

In the CY 2011 PFS final rule with comment period (75 FR 73411), we stated “that when the Health Risk Assessment is incorporated in the AWV, we will reevaluate the values for HCPCS codes G0438 and G0439”. As discussed in the CY 2011 PFS final rule with comment period, the services described by CPT codes 99204 and 99214 already include ‘preventive assessment' forms. For CY 2012, we believe that the current payment crosswalk for HCPCS codes G0438 and G0439 continue to be most accurately equivalent to a level 4 E/M new or established patient visit; and therefore, we are proposing to continue to crosswalk HCPCS codes G0438 and G0439 to CPT codes 99204 and 99214, respectively.

AWV - Initial Health Risk Assessment Establishment of an individual's medical and family history. Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual. Measurement of an individual's height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history. Detection of any cognitive impairment that the individual may have. Review of the individual's potential (risk factors) for depression, Review of the individual's functional ability and level of safety, based on direct observation. Review of the individual's functional ability and level of safety, based on direct observation Establishment of the following: ++ A written screening schedule, such as a checklist, for the next 5 to 10 years ++ A list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended. 9. Furnishing of personalized health advice to the individual and a referral, as appropriate. 10. Any other element determined appropriate through the National Coverage Determination process.

AWV - Subsequent Health Risk Assessment An update of the individual's medical and family history. An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing personalized prevention plan services. Measurement of an individual's weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history. Detection of any cognitive impairment, as that term is defined in this section, that the individual may have. An update to both of the following: ++ The written screening schedule for the individual as that schedule was developed at the first AWV providing personalized prevention plan services. CMS-1503-FC 761 ++ The list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway for the individual as that list was developed at the first AWV providing personalized prevention plan services. 7. Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs as that advice and related services are defined in paragraph (a) of this section. 8. Any other element determined through the NCD process.

Don’t Forget to bill your ACP along with the AWV so the patient does not receive a bill… www.thecodingeducator.com

ACP and RVUs

Modifier -33

Definition of -33

Breast & Pelvic Examination

Breast / Pelvic Exam The HCPCS Code: G0101 – Pelvic and Breast Exam The Diagnosis Codes Z01.411 or Z01.419 Routine gynecological exam Z12.72 Screening for neoplasm of the vagina Z12.89 Screening of woman without a cervix Z12.4 Screening for neoplasm of cervix Z77.9* - Every Year Presenting health hazards www.thecodingeducator.com

Four Questions Cervical Cancer High Risk Survey   Was your first sexual activity prior to the age of 16?  Yes  No Have you had more than 5 sexual partners?  Yes  No Do you have a history of sexually transmitted disease (including HIV) infection?  Yes  No Have you had fewer than 3 negative pap smears within the previous seven years?  Yes  No

Exam Required Female G/U: (7 of the following 11)  Breasts symmetrical. No masses, lumps, tenderness, dimpling or nipple discharge.  Rectal exam exhibits even sphincter tone, no hemorrhoids or masses. Pelvic  No external lesions. Normal hair distribution.  Urethral meatus pink, no lesions or discharge.  Urethra intact, no tenderness, masses, inflammation or discharge.  Bladder without tenderness or masses, no incontinence.  Vaginal mucosa moist and pink, without lesions or discharge.  Cervix pink, no lesions, odor, or discharge.  Uterus midline, non-tender, firm and smooth.  No adnexal masses, nodules or tenderness.  Anus and perineum intact. ___ No lesions, rashes, fissures, fistulas or external hemorrhoids. Wet Prep __________________ Hemoccult Pos. Neg.

Obtain Pap Smear The HCPCS Code: Q0091 - Obtaining screen pap smear The Diagnosis Codes Z01.411 or Z01.419 Routine gynecological exam Z12.72 Screening for neoplasm of the vagina Z12.89 Screening of woman without a cervix Z12.4 Screening for neoplasm of cervix Z77.9* - Every Year Presenting health hazards

Tobacco Cessation www.thecodingeducator.com

Tobacco Cessation Codes The CPT Codes: 99406: Smoking and tobacco cessation counseling; intermediate, greater than 3 minutes, up to 10 minutes, 99407: Smoking and tobacco cessation counseling; intensive, greater than 10 minutes, The Diagnosis Codes Medical dx of the patient at the time of the visit the tobacco is affecting If used with E/M, don’t forget modifier 25

New Tobacco Cessation Codes The HCPCS Codes: G0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes, G0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes, The Diagnosis Codes ICD-10 code F17.210 (dependent tobacco use disorder), or ICD-10 code Z87.891 (history of tobacco use).

Home Health & Care Plan

Home Health Certification The HCPCs Codes: G0179 – Re-certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care … G0180 - Certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care … www.thecodingeducator.com

Care Plan Oversight The HCPCS Codes: G0181 – Supervision of patient receiving Medicare-covered home health agency requiring complex multidisciplinary care…30 minutes or more G0182 - Supervision of patient receiving Medicare-approved hospice care requiring complex multidisciplinary care…30 minutes or more www.thecodingeducator.com

Extra Codes

G0442 – Annual alcohol misuse screening, 15 minutes G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes ICD-10: Z13.89 Frequency: G0442 – Annually G0443 – 4 x’s per year MCR Reimbursement G0442 - $17.13 G0443 - $24.19 www.thecodingeducator.com

G0444 - Annual Depression Screening – up to 15 minutes ICD-10: Z13.89   Frequency: Annually MCR Reimbursement: $17.13 www.thecodingeducator.com

G0446 - Intensive behavioral therapy to reduce cardiovascular disease risk, individual, face-to-face, Annual - 15 minutes.   ICD-10 codes: Z13.6 Frequency: Annually MCR Reimbursement: $24.19

IBT Counseling Risk reduction includes encouraging aspirin therapy for the primary prevention of cardiovascular disease when the benefits outweigh the risks for men ages 45 to 70 years and women55 to 79 years; Screening for high blood pressure for patients 18 years and older; and Intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and any other risk factors for cardiovascular and diet-related chronic disease

G0447 - Face-to-Face behavioral counseling for obesity – 15 minutes   ICD-10 codes: Z86.__ Codes Frequency: Please review next slide MCR Reimbursement: $24.19 .

One visit every week for the first month; One visit every other week for months 2 – 6; and One visit every month for months 7 -12 At the 6 month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed. To be eligible for additional face-to-face visits occurring once a month for an additional 6 months, beneficiaries must have lost at least 3kg (6.61 pounds) For beneficiaries who do not achieve a weight loss of at least 3 kg (6.61 pounds) during the first 6 months, a reassessment of their readiness to change and BMI is appropriate after an additional 6-month period.

Discussion Points Transitional Care Management CCM Services Preventive Services IPPE (Welcome to Medicare) AWV – Initial AWV – Subsequent ACP Breast/Pelvic Obtain Pap Smear Tobacco Cessation Counseling Home Health Certification and Recertification Bonus Codes

Questions

Discussion Points Transitional Care Management CCM Services Preventive Services IPPE (Welcome to Medicare) AWV – Initial AWV – Subsequent ACP Breast/Pelvic Obtain Pap Smear Tobacco Cessation Counseling Home Health Certification and Recertification Bonus Codes

Any Questions Direct: 706-483-4728 Office: 770-709-3598 E-mail: steve.adams@inhealthps.com Web: www.thecodingeducator.com Facebook: facebook.com/kingofcoders