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

4. 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

5. Transitional Care Management Chronic Care Management

7. 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

8. TCM Form

13. 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.

14. Medical Assistants

15. Billing Date

16. 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

17. 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.

18. 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

19. 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

20. 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

21. Preventive Medicine

22. 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

23. 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.

24. IPPE

25. 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

26. AWV

27. 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 through as appropriate to the patient's circumstances, and these codes continue to be noncovered by Medicare."

28. 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 and 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 and 99214, respectively.

29. 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.

30. 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.

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

33. ACP and RVUs

34. Modifier -33

35. Definition of -33

36. Breast & Pelvic Examination

37. Breast / Pelvic Exam The HCPCS Code: G0101 – Pelvic and Breast Exam
The Diagnosis Codes
Z 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

38. 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

39. 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.

40. Obtain Pap Smear The HCPCS Code: Q0091 - Obtaining screen pap smear
The Diagnosis Codes
Z 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

41. Tobacco Cessation

42. 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

43. 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 F (dependent tobacco use disorder), or
ICD-10 code Z (history of tobacco use).

44. Home Health & Care Plan

45. 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 …
G 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 …

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

47. Extra Codes

48. 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
G $17.13
G $24.19

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

50. G 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

51. 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

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

53. One visit every week for the first month; One visit every other week for months 2 – 6; and One visit every month for months 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.

54. 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

55. Questions

56. 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

57. Any Questions Direct: 706-483-4728 Office: 770-709-3598
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