1. Final Rule 2016 Components Chronic Care Management Advanced Care Planning Transitional Care Management HCPCS codes on RHC Claims www.northamericanhms.com 888.968.0076

2. Chronic Care Management - RHCs Chronic Care Management was introduced as a Medicare benefit in 2015. It was not initially payable for RHCs. Effective 1.1.2016, RHCs can bill a separate line item for CCM services. CCM requirements are the same for all providers. www.northamericanhms.com 888.968.0076

3. CCM Payments to RHC Medicare will pay CCM services to RHCs based on current Physician Fee Schedule rates. The current Medicare allowable for 2016 is $40.84. www.northamericanhms.com 888.968.0076

4. Face-to-Face Requirement The face to face requirement for an RHC encounter is waived. This is a non-encounter benefit being paid to RHCs. www.northamericanhms.com 888.968.0076

5. CCM Payments to RHCs Co-insurance and deductibles will be applied to these services. Chronic Care Management Services are not payable at the same time as Transitional Care Management services or any other program that provides additional payment for care management services (outside of the RHC AIR). www.northamericanhms.com 888.968.0076

6. Chronic Care Management (99490) 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. Comprehensive care plan established, implemented, revised, or monitored. CMS Chronic Care Management Fact Sheet www.northamericanhms.com 888.968.0076

7. Chronic Condition Examples Alzheimer’s disease/ related dementia Depression Arthritis (osteoarthritis and rheumatoid) Diabetes AsthmaHeart failure Atrial fibrillationHypertension Autism spectrum disordersIschemic heart disease CancerOsteoporosis Chronic Obstructive Pulmonary Disease; www.northamericanhms.com 888.968.0076

8. CCM Practitioners Physicians and the following non-physician practitioners may bill the new CCM service: Certified Nurse Midwives Clinical Nurse Specialists Nurse Practitioners Physician Assistants Only one provider per calendar month may bill the CCM Service. CMS Chronic Care Management Fact Sheet www.northamericanhms.com 888.968.0076

9. Emphasis on Care Management “The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, therefore these practitioners cannot furnish or bill the service. However, CMS expects referral to or consultation with such physicians and practitioners by the billing practitioner to coordinate and manage care.” CMS Chronic Care Management Fact Sheet www.northamericanhms.com 888.968.0076

10. Clinical Professionals Only Services provided directly by an appropriate physician or non-physician practitioner, or by clinical staff incident to the billing physician or non-physician practitioner, count toward the minimum amount of service time required to bill the CCM service (20 minutes per calendar month). CMS Chronic Care Management Fact Sheet www.northamericanhms.com 888.968.0076

11. Supervision Exception CMS requires CCM services to be provided under the direct supervision (rather than general supervision) of a physician in an RHC. CMS plans on addressing this, but the change will not be implemented until at least January 2017. www.northamericanhms.com 888.968.0076

12. Structured Data “Record the patient’s demographics, problems, medications, and medication allergies and create structured clinical summary records using certified EHR technology.” CMS Chronic Care Management Fact Sheet www.northamericanhms.com 888.968.0076

13. Care Plan Create a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues). Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record. Ensure the care plan is available electronically at all times to anyone within the practice providing the CCM service. S Share the care plan electronically outside the practice as appropriate. CMS Chronic Care Management Fact Sheet www.northamericanhms.com 888.968.0076

14. Care Availability Ensure 24-hour-a-day, 7-day-a-week (24/7) access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs. www.northamericanhms.com 888.968.0076

15. Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments. Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care. Do this through telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation. Care Availability www.northamericanhms.com 888.968.0076

16. Initial Examination CCM services may only be initiated after one of the following: Welcome to Medicare/IPPE Visit Annual Wellness/Subsequent Annual Wellness Visit Complete/Comprehensive Exam www.northamericanhms.com 888.968.0076

17. CCM Patient Education The eligible beneficiary must be informed about the availability of CCM services from the RHC or FQHC and provide his or her written agreement to have the services provided, including the electronic communication of the patient's information with other treating providers as part of care coordination. www.northamericanhms.com 888.968.0076

18. CCM Patient Discussion This would include a discussion with the patient about what CCM services are: how they differ from any care management services the RHC or FQHC currently offers, how these services are accessed, how the patient's information will be shared among others, that a non RHC or FQHC cannot furnish or bill for CCM services during the same calendar month that the RHC or FQHC furnishes CCM services, the applicability of coinsurance even when CCM services are not delivered face-to-face in the RHC or FQHC, and any care management services that are currently provided will continue even if the patient does not agree to have CCM services provided. www.northamericanhms.com 888.968.0076

19. CCM Discussion Requirements At the time the agreement is obtained, the eligible beneficiary must be informed that the agreement for CCM services could be revoked by the beneficiary at any time either verbally or in writing, and the RHC or FQHC practitioner must explain the effect of a revocation of the agreement for CCM services. The RHC or FQHC must provide a written or electronic copy of the care plan to the beneficiary and record this in the beneficiary's electronic medical record. www.northamericanhms.com 888.968.0076

20. Discussion Summary Document the discussion with the patient. Note that the patient has been informed of the co-insurance. Note that the patient has agreed to the service. Explain how the patient can revoke the agreement. www.northamericanhms.com 888.968.0076

21. Certified EHR RHCs and FQHCs must use technology certified to the edition(s) of certification criteria that is, at a minimum, acceptable for the EHR Incentive Programs as of December 31st of the year preceding each CCM payment year to meet the following core technology capabilities: Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary. www.northamericanhms.com 888.968.0076

22. CCM Cost Reporting The language regarding how to report costs on the RHC cost report is misleading. They are technically allowable on the cost report. They will be reported in such a manner that they will not affect the RHC all-inclusive rate. www.northamericanhms.com 888.968.0076

23. Chronic Care Management (99490) Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: www.northamericanhms.com 888.968.0076

24. CCM Billing – Stand Alone www.northamericanhms.com 888.968.0076

25. CCM with Billable Visit www.northamericanhms.com 888.968.0076

26. Advanced Care Planning – Surprise! This was added as a new RHC benefit with in conjunction with CCM services. www.northamericanhms.com 888.968.0076

27. Advanced Care Planning (99497) Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate). www.northamericanhms.com 888.968.0076

28. Advanced Care Planning (99498) Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure). www.northamericanhms.com 888.968.0076

29. ACP – Stand Alone Encounter www.northamericanhms.com 888.968.0076

30. ACP As part of Annual Wellness www.northamericanhms.com 888.968.0076

31. CCM Med Learn Matters 9234 https://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM92 34.pdf www.northamericanhms.com 888.968.0076

32. CCM Cost Reporting The language regarding how to report costs on the RHC cost report is misleading. They are technically allowable on the cost report. They will be reported in such a manner that they will not affect the FQHC PPS rate. www.northamericanhms.com 888.968.0076

33. TIPS: Chronic Care Management Services Don't simply bill on the last day. 99490 is based on providing at least 20 minutes of care to eligible patients (i.e. those meeting the chronic conditions requirement). Because the time is cumulative, you may be tempted to bill 99490 on the last day of the month. This may result in no payment if another provider bills 99490 before you. source: Kathy Bryant, director of the Division of Practitioner Services, CMS at AMA CPT Symposium, Nov 2014 www.northamericanhms.com 888.968.0076

34. Advanced Care Planning (99497) Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate). www.northamericanhms.com 888.968.0076

35. Advanced Care Planning (99498) Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure). www.northamericanhms.com 888.968.0076

36. Advanced Care Planning Advanced Care Planning can be billed as a stand-alone visit. www.northamericanhms.com 888.968.0076

37. 100.4 - Transitional Care Mgmt TCM services can be billed as a stand-alone visit if it is the only medical service provided on that day with a RHC or FQHC practitioner and it meets the TCM billing requirements. If it is furnished on the same day as another visit, only one visit can be billed. www.northamericanhms.com 888.968.0076

38. G-Code for ACP/TCM Advanced Care Planning and Transitional Care Management should both be reported using G0467 – Established Patient. CCM does not require a face-to-face visit. www.northamericanhms.com 888.968.0076

39. Medicare Preventive Reference Follow these links to: Medicare Preventive Services Quick Chart CMS Preventive Services Center Medlearn Matters 9234Medlearn Matters 9234. Chronic Care Management (CCM) Services for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). November 15, 2015 www.northamericanhms.com 888.968.0076

40. Reporting Services Beginning on April 1, 2016, RHCs are required to report the appropriate HCPCS code for each service line along with a revenue code on their Medicare claims. RHC qualifying medical visits are typically Evaluation and Management (E/M) type of services or screenings for certain preventive services. www.northamericanhms.com 888.968.0076

41. Total Qualifying Visit Line Medicare does not adjudicate RHC claims based on the 0001 Total Charge amount. Medicare adjudicates RHC claims using the Qualifying Visit Line. The qualifying visit line should be the sum of all RHC charges subtracted by any preventive services. www.northamericanhms.com 888.968.0076

42. Line Item Messages Group code CO- Contractual obligation; CARC 97 – The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. RARC M15 - Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed. www.northamericanhms.com 888.968.0076

43. Qualifying Visit Code SetsFromThrough Office Visit Codes99201 -99215 Nursing Home Visit Codes99304 -99308 NH Discharge Codes99315 -99316 NH Annual Assessment99318 -- Domicile Visits - New99324 -99328 Domicile Visits – Est Pt99334 -99337 Home Visits – New99341 -99345 Home Visit – Established99347 -99350 Transitional Care99495 -99497 Qualifying Visit List - Medical www.northamericanhms.com 888.968.0076

44. Encounter Codes - Wellness Qualifying CodeDescription G0402Initial preventive exam G0438Annual Wellness Visit/Personalized Plan, Initial G0439Annual Wellness Visit/Personalized Plan, Subsequent www.northamericanhms.com 888.968.0076

45. Behavioral Health – Qualifying Visits Visit CodeDescription 90791Psychiatric diagnostic evaluation 90792Psychiatric diagnostic evaluation w/ Medical Services 90832Psych Therapy Patient/ Family 30 minutes 90834Psych Therapy Patient/ Family 45 minutes 90837Psych Therapy Patient/ Family 60 minutes 90839Psych Therapy Patient/ Family Crisis initial 60 min 90845Psychoanalysis www.northamericanhms.com 888.968.0076

46. Qualifying Visit List – Eye Exams HCPCS CodeShort Description 92002Eye exam new patient 92004Eye exam new patient 92012Eye exam establish patient 92014Eye exam tx estab pt 1/>vst www.northamericanhms.com 888.968.0076

47. Expanded QVL CMS has expanded the Qualifying Visit List on multiple occasions. The full list can be found at: RHC Qualifying Visit List https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/FQHCPPS/Downloads/RHC- Qualifying-Visit-List.pdf www.northamericanhms.com 888.968.0076

48. Revenue Codes The following revenue codes are used on UB04 claims: 0521 -Clinic Visit at RHC by qualified provider; 0522 -Home visit by RHC provider; 0524 - Visit by RHC provider to a Part A SNF bed; 0525 -Visit by RHC provider to a SNF, NF or other residential facility (non-Part A); 0527 -Visiting Nurse service in home health shortage area 0528 -Visit by RHC provider to other non-RHC site (scene of an accident) www.northamericanhms.com 888.968.0076

49. More Revenue Codes – 4.1.2016 0250 – Pharmacy (Does not need the HCPCS) 0300 – Venipuncture 0636 – Injection/Immunization 0780 – Telehealth 0900 – Behavioral Health www.northamericanhms.com 888.968.0076

50. Revenue Codes The qualifying visit line must include the total charges for all the services provided during the encounter/visit. RHCs can report incident to services using all valid revenue codes except 002x-024x, 029x, 045x, 054x, 056x, 060x, 065x, 067x-072x, 080x- 088x, 093x, or 096x-310x. RHCs should report the most appropriate revenue code for the services being performed. (MLN 9269) www.northamericanhms.com 888.968.0076

51. Billing Example #1 www.northamericanhms.com 888.968.0076 An established patient is seen and a qualifying visit of 99213 for $100 is generated. The applicable coinsurance and/or deductible shall be based upon $100. Medicare will pay the encounter at 80% of the AIR. The patient will be responsible for $20.00 in co-insurance. www.northamericanhms.com 888.968.0076

52. Billing Example #2: Medical Services Plus Ancillary A Medicare beneficiary is seen for 99213 for a charge of $100. A Toradol injection (J1885) for $30 was performed. www.northamericanhms.com 888.968.0076 ServiceCharge 99213$100.00 J1885$30.00 Total Charges$130.00 www.northamericanhms.com 888.968.0076

53. Billing Example #2 – UB Fields Medical Visit plus Ancillary www.northamericanhms.com 888.968.0076 The charge amount for Toradol ($30.00) will be added to the 99213 ($100) for a qualifying visit line of $130.00. The total charge line is inaccurate. www.northamericanhms.com 888.968.0076

54. Service Detail Service detail lines can be reported as $.01 or greater. The additional services lines CAN be reported as $.01. This eliminates artificial inflation of revenue, adjustments, and AR. www.northamericanhms.com 888.968.0076

55. Billing Example #2 – Alternative Medical Visit plus Ancillary www.northamericanhms.com 888.968.0076 The Toradol charge amount ($30.00) plus $.01 for the line item is bundled with the $100 charge on the 99213 qualifying visit line. Medicare will use the line with the qualifying visit code (99213) to determine the total charge and calculate co- insurance. www.northamericanhms.com 888.968.0076

56. Billing Example #3: Medical Services Plus EKG A Medicare beneficiary is seen for 99213 for a charge of $100. A EKG (93005/93010) for $75/$30. www.northamericanhms.com 888.968.0076 ServiceCharge 99213$100.00 93005 EKG-TC$45.00 93010 EKG-PC$30.00 Total Charges$175.00 www.northamericanhms.com 888.968.0076

57. Billing Example #3 – Medical Visit plus EKG www.northamericanhms.com 888.968.0076 The EKG-PC charge amount is bundled with the 99213 on the RHC claim. A 93005 will be billed to Medicare Part B/FFS under the physician/group (IRHC) or Hospital P-TAN (PBRHC). www.northamericanhms.com 888.968.0076

58. Billing Example #3 – Alternative Medical Visit plus EKG www.northamericanhms.com 888.968.0076 The charge for the EKG-PC ($45.00) is bundled with the 99213 charge ($100.00) on the RHC claim. The EKG-PC is reported as a $.01 line item. A 93005 will be billed to Medicare Part B/FFS under the physician/group (IRHC) or Hospital P-TAN (PBRHC). www.northamericanhms.com 888.968.0076

59. Claim Example #4: Mental Health Services Mental Health Services RHCs shall report one service line per mental health encounter/visit with revenue code 0900 and a qualifying mental health visit from the RHC Qualifying Visit List. www.northamericanhms.com 888.968.0076

60. Billing Example #5 – Preventive/Ancillary www.northamericanhms.com 888.968.0076 An established patient is seen and a qualifying visit of 99213 for $100 is generated. A breast/pelvic exam was performed for $75.00. A venipuncture was taken for $20.00. The charge for the pelvic exam should NOT be bundled in the 99213 line since there will be no co-insurance applied to the preventive service. The $20.00 venipuncture charge will be bundled with the 99213 charge for $100.00. www.northamericanhms.com 888.968.0076

61. Billing Example #5 – Alternative Preventive/Ancillary www.northamericanhms.com 888.968.0076 An established patient is seen and a qualifying visit of 99213 for $100 is generated. A breast/pelvic exam was performed for $75.00. A venipuncture was taken for $20.00. The charge for the pelvic exam should NOT be bundled in the 99213 line since there will be no co-insurance applied to the preventive service. The $20.00 venipuncture charge will be bundled with the 99213 charge for $100.00. www.northamericanhms.com 888.968.0076

62. Billing Example #5: Medical Services Plus Procedure A Medicare beneficiary is seen for 99213 for a charge of $100. A minor surgical procedure (11100) for $150 was performed. www.northamericanhms.com 888.968.0076 ServiceCharge 99213$100.00 11100$150.00 Total Charges$250.00 www.northamericanhms.com 888.968.0076

63. Billing Example #6 – Medical Visit plus Procedure www.northamericanhms.com 888.968.0076 The laceration repair charge of $150.00 is bundled with the $100.00 office visit charge. The $400 total charge is irrelevant. www.northamericanhms.com 888.968.0076

64. Billing Example #6 – Alternative Medical Visit plus Procedure www.northamericanhms.com 888.968.0076 Medicare will use the line with the qualifying visit code (99213) to determine the total charge and calculate co- insurance. www.northamericanhms.com 888.968.0076

65. Encounter Billing – October 1, 2016 In April 2016, CMS instructed RHCs to hold claims only for a billable visit shown in red on the RHC QVL until October 1, 2016. Upon billing these claims and/or for claim adjustments beginning on October 1, 2016, RHCs shall add modifier CG (policy criteria applied) to the line with all the charges subject to coinsurance and deductible. www.northamericanhms.com 888.968.0076

66. Procedure only (Red QVL) – October 1, 2016 www.northamericanhms.com 888.968.0076

67. Multiple Encounters “Encounters with more than one RHC or FQHC practitioner on the same day, or multiple encounters with the same RHC or FQHC practitioner on the same day, constitute a single RHC or FQHC visit, regardless of the length or complexity of the visit or whether the second visit is a scheduled or unscheduled appointment.” (Medicare Benefit Policy Manual. Chapter 13. Section 40.3) www.northamericanhms.com 888.968.0076

68. Multiple Encounters are allowed when: The patient, subsequent to the first visit, suffers an illness or injury that requires additional diagnosis or treatment on the same day (2 visits), or The patient has a medical visit and a mental health visit on the same day (2 visits), or The patient has his/her IPPE and a separate medical and/or mental health visit on the same day (2 or 3 visits). (Medicare Benefit Policy Manual. Chapter 13. Section 40.3) www.northamericanhms.com 888.968.0076

69. Modifier - 59 Modifier-59 is used when there are two encounters on the same day. Modifier-59 indicates that separate conditions being treated are totally unrelated. This would be used when a patient returns to the clinic later in the day with a separate illness or injury. www.northamericanhms.com 888.968.0076

70. Modifier-59 Example www.northamericanhms.com 888.968.0076

71. Questions?

72. My Contact Information Charles A. James, Jr. President and CEO North American Healthcare Management Services 9245 Watson Industrial Park St. Louis, MO 63126 888.968.0076 314.560.0098 Cell cjamesjr@northamericanhms.com www.northamericanhms.com