Wednesday, May 13, 2020

Engage and Educate Your Patients with Custom E-Visits and Virtual Check-Ins





Is your practice looking for ways to increase revenue while protecting vulnerable patients?
If so, mHealth Games can help!

We build custom e-visits, virtual check-ins, online assessments and patient education that can be launched from your patient portal.

In need of a patient portal?
We can help with that too! Our patient portals start at $2,500 and can be completed in 7-10 days.

Recent projects include:

  • COVID-19 – Real-time monitoring of symptoms with personalized instructions
  • Heart Failure – Monitor daily weight and BP to prevent exacerbations
  • Diabetes – Patient management and education
  • COPD – Patient management and education
  • Major Depression – Online assessment and daily check-in
  • Substance Use Disorder – Patient management and education
  • Dermatology – Assessment of patient submitted images of skin rashes and other lesions


E-Visits



In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient.

For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.

Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes

99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes

99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes

 G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes

G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.

VIRTUAL CHECK-INS




Medicare pays for these “virtual check-ins” (or Brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would generally apply to these services.

Doctors and certain practitioners may bill for these virtual check in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012). The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.  Standard Part B cost sharing applies to both. In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010).

HCPCS code G2012: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

HCPCS code G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.

RHCs and FQHCs

RHCs and FQHCs may bill G0071, payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an RHC or FQHC practitioner and RHC or FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or image by an RHC or FQHC practitioner, occurring in lieu of an office visit; (RHC or FQHC only). G0071 will be paid at $24.76 beginning March 1, an increase from the prior rate of $13.53.

RHCs and FQHCs may also bill the “messaging” codes 99421–99423, on-line digital services.

MACs will automatically reprocess claims with G0071 for claims processed after March 1. The new rate is a blended rate, based on the payment rates of 99421—99423, and the two HCPCS codes for virtual communication, G2012 and G2010.



Visit mHealth Games today or contact Kameron Gifford to learn more. 

Friday, April 24, 2020

Advanced Risk Adjustment for Value Based Payments



Are you looking for the best education available in risk adjustment, value-based payments and/or CDI?

Good News - You have found it!

Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE!

Do you need CMEs or CEUs? We have that too!

All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders.

Register your team ( 3 or more) today to save 10% on any 2020 Workshop!

Take advantage of Early Bird pricing and Save $100!

Overview:
  • Vast changes are coming to the way we purchase healthcare.
  • What should your team be doing now to be successful in the world of value-based payments? 
  • How do HCCs impact benchmarks and quality scores?
  • Review CMS-HCC Model V24 for risk adjustment in 2020 and NEW HCCs that have been added to the model. 
  • Discuss the importance of managing HCCs year over year. What resources are available from CMS to help? 
  • Take a deep dive into the 20 most common HCCs per Medpac data. 
  • Common GAPS in claims and encounter data that lead to inaccurate risk scores. 

Who Should Attend?
-Providers - MDs, DOs, PAs, and NPs
-Medical Directors - Medicare Advantage, ACOs, CPC+ and Medicaid
-Hospitals and Academic Medical Centers
-Medical Coders, Billers and CDI Specialists
-Executive Leaders, Administrators, Directors and Managers
-MSO and IPA Teams
-Rural Health Centers, FQHCs and Community Health Centers
-Health Alliance Members and Medical Society Members
-Medicare, Medicare Advantage, Medicaid and Commercial Plans
  

Each Attendee will Receive ($130):
 - Color copy of the presentation
 - 2020 CMS-HCC Quick Coder
 - Laminated HCC and CDI Tools
 - CME from AAFP and AMA
 - CEU from AAPC


To REGISTER for a WORKSHOP

To SPONSOR an EVENT
Please email Kameron Gifford


Early Bird Pricing and Group Discounts
Register NOW to save $100 with Early Bird Pricing!
Bring the WHOLE TEAM!
 Register 3 and save 10% on your order!
 Register 4 and use the code TEAM4 to save 20% on your order!



Tuesday, April 21, 2020

Billing Virtual Services During COVID-19


CMS has broadened access to Medicare telehealth services on a temporary and emergency basis due to the Coronavirus. What does this mean for your practice? Which services are covered? What are the documentation and coding rules?
Sections: 
  1. Medicare Virtual Visits Review
  2. Medicare Virtual Visit Quiz
Course Objectives:
Review the following
  • Expansion of telehealth services due to the COVID-19 health emergency. 
  • Three basic types of virtual visits covered under the waiver. 
  • Which patients are eligible for the services?
  • Specific types of communication allowed.
  • Does cost sharing apply? 
  • What is the correct POS?
  • Which modifier should be assigned?


Thursday, April 16, 2020

Postponement of 2019 Benefit Year HHS-operated Risk Adjustment Data Validation


To facilitate the nation’s response to COVID-19, CMS is announcing the postponement of the 2019 benefit year HHS Risk Adjustment Data Validation (HHS-RADV) process.

This action will allow individual and small group health insurance issuers and providers to focus on the health and safety threats currently faced by enrollees, participants, and other impacted individuals due to the COVID-19 pandemic.

CMS intends to provide future guidance in the summer of 2020 on the updated timeline for 2019 benefit year HHS-RADV activities that are planned to begin in 2021.

View the entire notice here: https://www.cms.gov/files/document/2019-HHS-RADV-Postponement-Memo.pdf


Let's Talk About Risk



Approved by the AAPC for 3 hours of CEUs


Overview:

This course is a basic introduction to risk adjustment and HCC coding for coders, physicians
and other healthcare professionals. 


Key Objectives Include:

•Learn what an HCC is and what documentation is needed to support it.

•Discover what guidelines impact the CMS-HCC risk adjustment model. 

•Review the components of a risk score and learn how it is calculated. 

•Examine the top 20 HCCs for Medicare beneficiaries per MedPAC data. 

Register for a free account today: www.erm365.org to enroll in the course and start learning.


A link to print your AAPC CEU certificate will be available once you have completed the course. 









Sunday, April 12, 2020

Applicability of diagnoses from telehealth services for risk adjustment


The 2019 Coronavirus Disease (COVID-19) pandemic has resulted in an urgency to expand the use of virtual care to reduce the risk of spreading the virus; CMS is stating that Medicare Advantage (MA) organizations and other organizations that submit diagnoses for risk adjusted payment are able to submit diagnoses for risk adjustment that are from telehealth visits when those visits meet all criteria for risk adjustment eligibility, which include being from an allowable inpatient, outpatient, or professional service, and from a face-to-face encounter. This use of diagnoses from telehealth services applies both to submissions to the Risk Adjustment Processing System (RAPS), and those submitted to the Encounter Data System (EDS). Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face requirement when the services are provided using an interactive audio and video telecommunications system that permits real-time interactive communication.

While MA organizations and other organizations that submit diagnoses for risk adjusted payment identify which diagnoses meet risk adjustment criteria for their submissions to RAPS, MA organizations (and other organizations as required) report all the services they provide to enrollees to the encounter data system and CMS identifies those diagnoses that meet risk adjustment filtering criteria. In order to report services to the EDS that have been provided via telehealth, use place of service code “02” for telehealth or use the CPT telehealth modifier “95” with any place of service.

Questions can be addressed to RiskAdjustment@cms.hhs.gov, please specify, “Applicability of telehealth services for risk adjustment” in the subject line.


Wednesday, April 8, 2020

2021 Medicare Advantage and Part D Rate Announcement Fact Sheet

On April 6th, the Centers for Medicare & Medicaid Services (CMS) published the Calendar Year (CY) 2021 Rate Announcement, finalizing Medicare Advantage (MA) and Part D payment methodologies for CY 2021. This Rate Announcement addresses comments received on Parts I and II of the CY 2021 Advance Notice, published on January 6 and February 5, 2020, respectively. The final policies in the Rate Announcement will continue to modernize and maximize competition within the MA and Part D programs. 
COVID-19 Outbreak
The health and safety of America’s patients and provider workforce in the face of the Coronavirus Disease 2019 (COVID-19) outbreak is the top priority of the Trump Administration and CMS. We are working around the clock to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. The 2021 Rate Announcement is an example of how CMS is focused on implementing the policies that matter most for ensuring continuous and predictable payments across the health care system and ensure care can be provided where it is needed. While the Rate Announcement does not catalog CMS’ actions related to the COVID-19 outbreak, an overview of CMS’ actions related to the outbreak for MA organizations, PACE organizations, and Part D sponsors can be found at: https://www.cms.gov/files/document/covid-ma-and-part-d.pdf. The agency is also communicating with stakeholders, responding to inquiries through the HPMS system, and developing further guidance on issues related to the COVID-19 outbreak.
To keep up with the White House Task Force actions in response to the COVID-19 outbreak, visit Coronavirus.gov.  For information specific to CMS, please visit the Current Emergencies Website.

2021 Rate Announcement
After considering all comments received, CMS is finalizing updates and changes to the methodologies used to pay MA organizations, PACE organizations, and Part D sponsors discussed in Parts I and II of the CY 2021 Advance Notice.
Net Payment Impact
The chart below indicates the expected impact of the updated methodologies on plan payments relative to last year. 
Year-over-Year Percentage Change in Payment
1Rebasing/re-pricing impact is dependent on finalization of the average geographic adjustment index, which was not available with the publication of the 2021 Advance Notice.
2For 2021, the rebasing/repricing impact reflects the impact of the kidney acquisition cost carve-out.
3The total does not include an adjustment for underlying coding trend. For 2021, CMS expects the underlying coding trend to increase risk scores, on average, by 3.56%.

2021 Part C Risk Adjustment Model
CMS is finalizing as proposed the continued phase-in of the 2020 CMS-Hierarchical Condition Categories (HCC) model. The 21st Century Cures Act requires that CMS phase in changes to risk adjustment payments based on section 1853(a)(1)(I) of the Social Security Act over a three-year period, with full implementation by 2022. In order to continue phasing in the model that meets statutory requirements (i.e., the 2020 CMS-HCC model), CMS is finalizing the proposal to calculate risk scores for CY 2021 payments to MA organizations and certain demonstrations as the sum of:
  • 75% of the risk score calculated with the 2020 CMS-HCC model and
  • 25% of the risk score calculated with the 2017 CMS-HCC model.
This represents a change from the blend for CY 2020 of 50% of the risk score calculated with the 2020 CMS-HCC model and 50% of the risk score calculated with the 2017 CMS-HCC model.
Using Encounter Data
CMS calculates risk scores using diagnoses submitted by MA organizations and from Medicare fee-for-service (FFS) claims. Historically, CMS has used diagnoses submitted into CMS’ Risk Adjustment Processing System (RAPS) by MA organizations for the purpose of calculating risk scores for payment. In recent years, CMS began collecting encounter data from MA organizations, which also includes diagnostic information. CMS began using diagnoses from encounter data to calculate risk scores for CY 2015, and for CY 2016, CMS blended 10% of the encounter data-based risk score with 90% of the RAPS-based risk score. CMS has since continued to use a blend, calculating risk scores with 25% encounter data and 75% RAPS data for CY 2017, 15% encounter data and 85% RAPS data for CY 2018, 25% encounter data and 75% RAPS data for CY 2019, and 50% encounter data and 50% RAPS data for CY 2020.
For CY 2021, CMS is finalizing the proposal to calculate risk scores for payment to MA organizations and certain demonstrations as the sum of 75% of the encounter data-based risk score and 25% of the RAPS-based risk score. CMS is finalizing the proposal to calculate the encounter data-based risk scores with the 2020 CMS-HCC model and the RAPS-based risk scores with the 2017 CMS-HCC model.
For Programs of All-Inclusive Care for the Elderly (PACE) organizations for CY 2021, CMS is finalizing the proposal to continue to calculate risk scores using the 2017 CMS-HCC model by pooling risk adjustment-eligible diagnoses from encounter data, RAPS data, and FFS claims (with no weighting).
Medicare Advantage Coding Pattern Adjustment
Each year, as required by law, CMS makes an adjustment to plan payments to reflect differences in diagnosis coding between MA organizations and FFS providers. For CY 2021, CMS is finalizing the proposal to apply a coding pattern adjustment of 5.90%, which is the minimum adjustment for coding intensity required by the statute.
Medicare Advantage End-Stage Renal Disease (ESRD) Payment
Pursuant to section 1853(a)(1)(H) of the Act, CMS establishes “separate rates of payment” for ESRD beneficiaries enrolled in MA plans. Outside of the exclusion of organ acquisition costs for kidney transplants from MA ESRD rates (mandated by the 21st Century Cures Act; discussed below), the methodology proposed in the Advance Notice and finalized in the Rate Announcement for the CY 2021 ESRD rates remains unchanged from the methodology used continuously for the past several years. The final trend factor that will apply to the MA ESRD state-level rates for 2021 is 4.04%, which is higher than the Advance Notice estimate of 2.8%.
Exclusion of Kidney Organ Acquisition Costs from MA Benchmarks
The 21st Century Cures Act amended the Social Security Act to allow all Medicare-eligible individuals with ESRD to enroll in MA plans beginning January 1, 2021. With this enrollment policy change, the Cures Act also made related payment changes in the MA and FFS programs. Effective January 1, 2021, MA organizations will no longer be responsible for organ acquisition costs for kidney transplants for MA beneficiaries, and such costs will be excluded from MA benchmarks and covered under the FFS program instead. The CY 2021 Advance Notice provided a step-by-step description of the methodology by which CMS will estimate the kidney organ acquisition costs to carve out from MA ESRD and non-ESRD benchmarks, which we are finalizing through the Rate Announcement. PACE organizations will continue to cover organ acquisition costs for kidney transplants and CMS will continue to include the costs for kidney acquisitions in the development of PACE payment rates.
Puerto Rico
A far greater proportion of Medicare beneficiaries receive benefits through MA in Puerto Rico than in any other state or territory. The policies finalized for 2021 will continue to provide stability for the MA program in the Commonwealth and to Puerto Ricans enrolled in MA plans. These policies include basing the MA county rates in Puerto Rico on the relatively higher costs of beneficiaries in FFS who have both Medicare Parts A and B, continuing the statutory interpretation that permits certain counties in Puerto Rico to qualify for an increased quality bonus adjusted benchmark, and applying an adjustment to reflect the nationwide propensity of beneficiaries with zero claims.
Part C and D Star Ratings
As part of the Administration’s effort to increase transparency and seek public comment on the Part C and D Star Ratings program, CMS codified the methodology for the Part C and D Star Ratings program in the CY 2019 Medicare Part C and D Final Rule, published in April 2018 for the 2021 Star Ratings. The Advance Notice provided information and updates that those regulations require us to announce through the process described in section 1853(b) of the Social Security Act for changes in, and adoption of, payment and risk adjustment policies. In addition, we solicited input on future measures and concepts as we continue to enhance the Star Ratings over time.
Please note that in the Medicare and Medicaid Programs: Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency Interim Final Rule (CMS-1744-IFC); https://www.federalregister.gov/documents/2020/04/06/2020-06990/medicare-and-medicaid-programs-policy-and-regulatory-revisions-in-response-to-the-covid-19-publicput on display at the Office of the Federal Register website on March 31, 2020 and scheduled to be published in the Federal Register on April 6, 2020, CMS adopted several changes to the 2021 Star Ratings to address the disruption to data collection and plan performance in 2020 posed by the COVID-19 pandemic. Specifically, this rule eliminates the 2020 collections of Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) data and replaces the measures calculated based on those HEDIS and CAHPS data collections with earlier values from the 2020 Star Ratings that would not have been affected by the public health threats posed by COVID-19. It establishes how we will assign Star Ratings for 2021 in the event that the virus prevents CMS from having validated data or results in systemic data integrity issues, or if CMS’s functions become focused on only continued performance of essential Agency functions due to the pandemic. It also modifies the current rules for the 2021 Star Ratings to replace any measure that has a systemic data quality issue due to the COVID-19 outbreak with the measure-level Star Rating and score from the 2020 Star Ratings. 
The IFC also makes changes for the 2022 Star Ratings to remove guardrails and expand the hold harmless provision for the Part C and D improvement measures to include all contracts. For just the 2022 Quality Bonus Payment (QBP) ratings that are based on 2021 Star Ratings, we are modifying the definition of new MA plan: we will treat an MA plan as a new MA plan if it is offered by a parent organization that has not had another MA contract for the previous 4 years.
In Attachment VI of the the CY 2021 Rate Announcement, CMS is finalizing June 30, 2020 as the date by which plans must submit their requests for review of the appeals and complaints measures data. The Rate Announcement also lists the measures included in the Part C and D Improvement measures and the values for the Categorical Adjustment Index for the 2021 Star Ratings. The policy for adjustments to Star Ratings in the event of extreme and uncontrollable circumstances, such as major hurricanes, is the same as the one implemented for the 2020 Star Ratings and codified in regulation for the 2022 Star Ratings. This policy will only impact measures that do not already revert back to the 2020 measure-level Star Rating and associated measure score, as a result of the adjustments to the 2021 Star Ratings codified in the Interim Final Rule. 
Additionally, as part of our efforts to lower prescription drug costs for Medicare beneficiaries and strengthen competition for generic products, CMS solicited feedback on a generic utilization Part D measurement concept through the CY 2021 Advance Notice. CMS encourages Part D sponsors to leverage favorable tier placement and effective formulary management tools to incentivize beneficiaries to fill generic alternatives over branded products. We reviewed the feedback received and will consider it for any potential future development of generic utilization measures for the Part D Star Ratings program.
Other measurement concepts that CMS solicited feedback on include:
  • End-Stage Renal Disease (ESRD) measures (Part C)
  • Prior Authorizations (Part C)
  • Physical Functioning Activities of Daily Living Patient-reported measure (Part C)
  • Initial Opioid Prescribing (Part D)
CMS will take feedback received into consideration and where appropriate share with the measure stewards.
Process
The CY 2021 Rate Announcement may be viewed by going to: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents.html and selecting “2021 Announcement.”
CMS will offer stakeholders an opportunity to discuss the 2021 Rate Announcement, as well as guidance related to the COVID-19 outbreak for MA organizations, PACE organizations, and Part D sponsors, with CMS staff during a call that will be scheduled in the near future. We will provide further details on this stakeholder call soon.



Thursday, April 2, 2020

Billing for Professional Telehealth Services During the Public Health Emergency

SPECIAL EDITION 
Tuesday, March 31, 2020 
Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. When billing professional claims for non-traditional telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with the Place of Service (POS) equal to what it would have been in the absence of a PHE, along with a modifier 95, indicating that the service rendered was actually performed via telehealth. As a reminder, CMS is not requiring the “CR” modifier on telehealth services. However, consistent with current rules for traditional telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims:
  • Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology, use GQ modifier
  • Furnished for diagnosis and treatment of an acute stroke, use G0 modifier
Traditional Medicare telehealth services professional claims should reflect the designated POS code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site. There is no change to the facility/non-facility payment differential applied based on POS. Claims submitted with POS code 02 will continue to pay at the facility rate.
There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.


Friday, March 27, 2020

Anthem Is Sued By US For Fraud



SDNY COURTHOUSE, March 26 -- The US has sued Anthem, Inc. for fraud, in a filing found by Inner City Press past 8 pm on March 26 on the docket of the U.S. District Court for the Southern District of New York. From the complaint, not yet assigned to any SDNY judge: "This is a civil fraud action brought by the Government against defendant Anthem, Inc. (“Anthem”) to recover treble damages sustained by, and civil penalties and restitution owed  to, the Government as result of Anthem’s violations of the False Claims Act (“FCA”), 31 U.S.C.  § 3729 et seq. 

As set forth below, Anthem knowingly disregarded its duty to ensure the accuracy  of the risk adjustment diagnosis data that it submitted to the Centers for Medicare and Medicaid  Services (“CMS”) for hundreds of thousands of Medicare beneficiaries covered by the Medicare  Part C plans operated by Anthem.  By ignoring its duty to delete thousands of inaccurate  diagnoses, Anthem unlawfully obtained and retained from CMS millions of dollars in payments  under the risk adjustment payment system for Medicare Part C.  Case As a Medicare Advantage Organization (“MAO”), Anthem was responsible for covering the cost of services rendered by healthcare providers like hospitals and doctors’ offices  for the Medicare beneficiaries enrolled in Anthem’s Part C plans.  Anthem, in turn, received  monthly capitated payments from CMS for providing such coverage.  See infra ¶¶ 21-39.

Anthem understood that CMS calculated the payments to Anthem pursuant to a risk adjustment system, under which the amounts of those payments were based directly on the  number and the severity of the diagnosis data — in the form of ICD diagnosis codes — that  Anthem submitted to CMS.  See infra ¶¶ 27-44.

In most cases, Anthem submitted the diagnosis  codes reported by providers in the claims and data that the providers submitted to Anthem to  seek payments for treating Medicare beneficiaries enrolled in Anthem’s Part C plans. 4. Anthem knew that, because the diagnosis codes it submitted to CMS affected payment directly, it had an obligation to ensure that its data submissions were accurate and  truthful, including by complying with the ICD coding guidelines adopted by CMS regulations.   See infra ¶¶ 45-50. 

Indeed, Anthem expressly promised CMS that it would “research and  correct” any “discrepancies” in its “risk adjustment data” submissions and that it would comply  with CMS’s regulatory and contractual requirement that diagnosis codes for risk adjustment  purposes must be substantiated by beneficiaries’ medical records.  See infra ¶¶ 79-82. 

In  addition, Anthem repeatedly attested to CMS that its risk adjustment diagnosis data submissions  were “accurate, complete, and truthful” according to its “best knowledge, information and  belief.”  See infra ¶¶ 83-90.  As Anthem knew, the promises and attestations it made to CMS  placed on Anthem an obligation to make good faith efforts to delete inaccurate diagnosis codes." We'll have more on this. The case is US v Anthem, 20-cv-2593 (UA).

http://www.innercitypress.com/sdny1anthemicp032620.html


Monday, March 23, 2020

Medicare Telemedicine Services

Medicare coverage and payment of virtual services


Summary of Medicare Telemedicine Services

INTRODUCTION:
Under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. These policy changes build on the regulatory flexibilities granted under the President’s emergency declaration. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19  – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.   
Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Innovative uses of this kind of technology in the provision of healthcare is increasing.  And with the emergence of the virus causing the disease COVID-19, there is an urgency to expand the use of technology to help people who need routine care, and keep vulnerable beneficiaries and beneficiaries with mild symptoms in their homes while maintaining access to the care they need. Limiting community spread of the virus, as well as limiting the exposure to other patients and staff members will slow viral spread.
EXPANSION OF TELEHEALTH WITH 1135 WAIVER: 
Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020.  A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients.  Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
Prior to this waiver Medicare could only pay for telehealth on a limited basis:  when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service. 
Even before the availability of this waiver authority, CMS made several related changes to improve access to virtual care.  In 2019, Medicare started making payment for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner. Medicare Part B separately pays clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal.
Medicare beneficiaries will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital which puts themselves and others at risk.
TYPES OF VIRTUAL SERVICES:
There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries summarized in this fact sheet:  Medicare telehealth visits, virtual check-ins and e-visits.
MEDICARE TELEHEALTH VISITS:  Currently, Medicare patients may use telecommunication technology for office, hospital visits and other services that generally occur in-person. 
  • The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  Distant site practitioners who can furnish and get payment for covered telehealth services (subject to state law) can include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals. 
  • It is imperative during this public health emergency that patients avoid travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness.  Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act.  To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.
KEY TAKEAWAYS:
  • Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances.
  • These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
  • Starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings.
  • While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home.
  • The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
  • To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.
VIRTUAL CHECK-INS: In all areas (not just rural), established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. We expect that these virtual services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation. 
Medicare pays for these “virtual check-ins” (or Brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would generally apply to these services.
Doctors and certain practitioners may bill for these virtual check in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012). The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.  Standard Part B cost sharing applies to both. In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010).
KEY TAKEAWAYS:
  • Virtual check-in services can only be reported when the billing practice has an established relationship with the patient. 
  • This is not limited to only rural settings or certain locations.
  • Individual services need to be agreed to by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient agreement. 
  • HCPCS code G2012: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
  • HCPCS code G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.
  • Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare telehealth visits, which require audio and visual capabilities for real-time communication.
E-VISITS:  In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.
Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:
  • 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes
  • 99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes
  • 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.
Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:
  • G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes
  •  G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes
  • G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.
KEY TAKEAWAYS:
  • These services can only be reported when the billing practice has an established relationship with the patient. 
  • This is not limited to only rural settings. There are no geographic or location restrictions for these visits.
  • Patients communicate with their doctors without going to the doctor’s office by using online patient portals.
  • Individual services need to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation. 
  • The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable.
  • The Medicare coinsurance and deductible would generally apply to these services.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA):  Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.  
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet


COVID-19 Telehealth Coding and Billing Practice Management Tips




This toolkit is intended to help practices make adjustments now, and in the coming weeks, due to COVID-19.  This CMS FAQ provides information about cost-sharing requirements for COVID-19 testing and treatment. Any new guidance for physicians will be posted on ACP’s COVID-19 resource page

https://www.acponline.org/practice-resources/business-resources/covid-19-telehealth-coding-and-billing-practice-management-tips