CMS Puts Patients Over Paperwork
CMS puts patients over paperwork with a new rule that addresses the prior authorization process. The new rule will empower patients, lower costs, and give providers the ability to give better care to their patients. Continue reading below to learn more about the new final rule.nnToday, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care.nn“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.”nnThe “CMS Interoperability and Prior Authorization” rule is the next phase of CMS interoperability rulemaking, aimed at improving data exchange while simultaneously reducing provider and patient burden. This final rule requires the payers regulated under this rule (namely, Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs (FFS) and issuers of individual market Qualified Health Plans (QHPs) on the Federally-facilitated exchanges (FFEs)) to implement application programing interfaces (APIs) that will give providers better access to data about their patients, and streamline the process of prior authorization. APIs are the foundation of smartphone applications, and when integrated with a provider’s electronic health record (EHR), they can enable data access at the touch of a button. By exchanging relevant health information between patients, providers and payers, APIs support a better health care experience for patients. Patients have easier access to their own health information, their providers have a more complete picture of their care, and patients can take their information with them as they move from plan to plan, and from provider to provider throughout the healthcare system. This ensures more coordinated, quality care, and less repetitive and unnecessary care that is costly.nnToday’s final rule requires Medicaid and CHIP (FFS) programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to include, as part of the already established Patient Access API, claims and encounter data, including laboratory results, and information about the patient’s pending and active prior authorization decisions. These payers are also required to share this data directly with patients’ providers if they ask for it and with other payers as the patient moves from one payer to another. In this way, patients, providers, and payers have the data when and where they need it, to help ensure that patients receive the best possible care. While Medicare Advantage plans are not included in and therefore not subject to this final rule, CMS is considering whether to do so in future rulemaking.nnPrior Authorization Burden ReductionnnPayers use prior authorization as a way to manage health care costs and ensure payment accuracy. For certain services, providers request approval from payers before rendering care to ensure that the payer will determine that the care is medically necessary, a threshold requirement for care to be reimbursed under the patients’ health coverage. This administrative process can be burdensome, and the challenges of the prior authorization process have motivated industry efforts to develop tools to increase automation. This final rule aims to reduce the inefficiencies and burdens of the prior authorization process for providers, and give them back time to focus on what matters most, treating patients in a timely manner.nnThe final rule requires Medicaid and CHIP FFS programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to build, implement, and maintain APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to support automation of the prior authorization process, specifically addressing the challenges raised by both providers and payers. The requirements of this rule specify that each of these payers will build an API-enabled documentation requirements look-up service, and make these public so providers may access documentation and prior authorization requirements from their EHR platforms. Once a provider knows what is required for each prior authorization, the next step is submitting it electronically. The final rule also requires Medicaid, CHIP, and QHP payers to implement and maintain prior authorization support APIs using the HL7 FHIR standard, which will advance a streamlined approach for communicating prior authorization requests and responses between those payers and provider EHR platforms or other practice management systems.nnThe final rule also requires Medicaid and CHIP (FFS) programs, and Medicaid and CHIP managed care plans to meet reduced decision timelines for prior authorizations. These payers will now have a maximum of 72 hours to make prior authorization decisions on urgent requests and seven calendar days for non-urgent requests, and all payers subject to the rule are required to provide a specific reason for any denial, which will allow providers some transparency into the process beginning January 1, 2024 or the rating period that starts on or after January 1, 2024. In addition, to promote accountability, the rule requires these payers, to make public, prior authorization metrics that demonstrate how they operationalize the prior authorization process. All of these requirements together will promote a more streamlined and efficient prior authorization process for providers and payers alike.nnThe rule will improve the patient experience as well. When a patient sees, for instance that a prior authorization is needed and has been submitted for a particular item or service, they will better understand the timeline for the process and be able to work with their provider to plan accordingly.nnToday’s final rule aims to improve longstanding inefficiencies in the healthcare system —including the lack of data sharing and access. This final rule expands the current Administration’s goals of quality and lower costs in health care as payers and providers will now have access to more complete patient histories, allowing for more coordinated and seamless patient care.n
There is a new HCPCS code G2212 for prolonged services with or without direct patient contact on the date of service. This new code has changes that influence when extra time starts during patient encounters. Continue reading below to learn more.nnWith All the changes come up in 2021 for Office and Outpatient encounters, if you are a CMS credentialed provider this topic cannot be emphasized enough. Part of the overhaul of the Evaluation and Management (E/M) guideline changes was the creation of a prolonged service code, 99417. Unfortunately, the requirements for this code will not be support by CMS, thus the creation of HCPCS code G2212. Below you will see two tables taken directly from CMS Manual, transmittal 10505.nnThe biggest difference is that extra time does not start once the maximum time for your base code, 99205 or 99215, has been exceeded but rather it begins at minute 89. (i.e. if your total encounter time for a particular encounter was 100 minutes, according to CPT you would report 99205 + 99417×2 vs. CMS you would report 99205 + G2212x1).nnThese charts should be printed out and added to you CPT manual for comparison to what AMA has released for code 99417 or kept in with your other quick reference tools.nn nn
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A new year means new CPT changes have been released. These changes apply to E/M office and other outpatient visit reporting. We’ve compiled a list of 30 FAQ’s so that you can start your 2021 reporting off right. Continue reading below to learn more.nnBy Ginger Avery, CPC, CPMA, CRCnJanuary 5, 2021nn1.Where can the CPT E/M code and guidelines be found? The CPT E/M code and guideline changes for 2021 can not only be found on the American Medical Associations (AMA) site at this link, but they can also be found in their entirety within the 2021 CPT Code books themselves. These guidelines include the new level of medical decision-making table and the 22 new definitions that help clarify what the MDM terms mean.nn2.Does pulling the lab results into the note constitute a “review of results” or do I need to document by stating that I have reviewed them? Moving forward information from old notes without comment does not add any value to the work that was performed and does not count. Did you review/analyze these results, what impact does this have on today’s visit? What is the clinical significance of this additional work?nn3.When tests are ordered during one visit and reviewed the same test during the next visit, can that count as a data point for both visits? With the new guidelines, we no longer have data “points”. Both encounters would support Limited data (low) with Category 1. The first encounter supports Category 1 for ordering of the test, the follow up encounter would support Category 1 for review of the results.nn4.Where does lifestyle counseling come into this? Preventive medicine counseling and/or risk factor reduction interventions (99401-99412) are time-based codes but do NOT follow the office visit E/M guidelines. Relevant visit details and total F2F time should be documented appropriately. Code selection is based on the F2F time spent with the patient.nn5.When reporting for total time, is it just time spent with patient at the encounter? No, in 2021, time is defined as the total encounter time on the date of service. This includes both F2F work and non-F2F work personally performed by the clinician.nn6.When dealing with complex patients where time is difficult to track will we have to revert to Medical Decision Making? With the new guidelines, you now have a choice, MDM or total encounter time. If total encounter time runs outside of the date of service or is challenging to track, then reporting based on the medical decision making may be a better choice. Do not undervalue the complexity by not documenting all the relevant work you do.nn7.Seeing how we cannot estimate for time that could be spent, say for a possible follow up phone call, how should we code to earn credit for that work? Time based reporting is only appropriate for time spent on the date of the encounter. Follow up phone calls on a later date cannot be reported based on time. MDM should be considered. In column 2 of the level of MDM chart, Category 3 provides credit when discussing the case with other clinicians or appropriate source. Be sure to document these details when true.nn8.Providers do use outpatient codes in the hospital if patient is in Observation status “not Inpatient”, I would assume these rules would apply to bill new/vs est pt when appropriate? Yes, the guideline updates are for office visits and other outpatient services.nn9.With the new time-based reporting, it seems that we absolutely need to sign off on our notes on the day of service. This is not always feasible given a busy day. In 2021, total encounter time includes completing documentation. If a clinician is unable to complete their note on the date of the encounter, reporting based on MDM may be a better choice.nn10.Some of these activities occur after the visit (complications/adverse reactions) – how can you account for that in your note for that day? Complications and adverse reactions may support an additional encounter when the need for evaluation and management may arise but would not be included on the date of the encounter unless that presentation was true during the visit.nn11.Do the E/M changes apply to outpatient or inpatient services? The 2021 E/M changes only apply to Outpatient services. Inpatient visits still need to follow the key component guidelines (1995 or 1997).nn12.Since history and physical exam are no longer required to level the visit, should these elements still be documented? Yes, history and exam are still part of an evaluation. The documented content should be focused on the clinically relevant details and cognitive thoughts of the clinician, not checkboxes or templated details. What is the nature of the presenting illness(es) (subject details with pertinent ROS)? Document a medically necessary exam. Documentation is about the quality of the story, not the quantity of details. Don’t import pages of past medical history or medication lists that aren’t relevant. Clinicians are encouraged to write notes that they would like to read.nn13.Do I still have to document ROS and PFSH? Yes, when clinically relevant. For example: Patient presents with chest pain. Has been having intermittent chest pain at rest for two weeks. No notable triggers. Positive for headaches and dizziness, no SOB. Patient has a past family history of CAD. Remember, documentation is all about the medically necessary story.nn14.When coding based on total time does the assessment and plan still need to be documented? Yes. Quality documentation should always be captured. Clinical impressions and plans that are well documented support the medical necessity for the services provided, regardless of how you choose to report the visit. Again, clinicians are encouraged to write notes that they would like to read.nn15.When coding based on total time and have also provided additional time-based services (advance care planning, counseling, etc.) how should those services be documented? The time associated with each visit should be separate and clearly identified to support each unique service.nn16.Are commercial plans required to adopt the revisions to E/M codes? Yes. The CPT code set, together with the U.S. Department of Health and Human Services’ Healthcare Common Procedure Coding System, has been adopted as the nation’s standard medical data code set. HIPAA requires that health plans use the most recent version of the medical data code set, they should be ready to implement the revisions Jan. 1, 2021.nn17.Who else besides clinicians needs to implement the 2021 E/M office visit changes? Other clinicians, coders, third-party plan administrators, and other health care-related entities should start using the revised code set Jan. 1. Physician practices should confirm that their contracted health plans and EHR vendors are integrating the revised codes into their software systems and will be ready Jan. 1, 2021.nn18.Can I still use my EHR’s coding calculator? Technically, Yes. It is important that clinicians confirm with their EHR vendor that their system’s code-selection application conforms to the revised codes and descriptors because the billing provider has the ultimate responsibility for appropriate coding. The EHR’s coding calculators are simply bean counters driven by templates and checkboxes; medically necessity cannot be quantified utilizing a point counting system. Often these systems are not set up with the appropriate guidelines and do not include additional instruction.nn19.Can we still bill 99201-99205 and 99211-99215 based on the 1995 and 1997 guidelines for dates of service on and after January 1, 2021? Office/outpatient visits PRIOR to January 1, 2021 may still be billed using the 1995 or 1997 guidelines. Clinicians must bill office/outpatient visits provided ON or AFTER January 1, 2021 using the CPT E/M code and guideline changes for 2021. Note: Based on the CPT changes, code 99201 is no longer valid for dates of service on and after January 1, 2021.nn20.Do the 2021 E/M code and guideline changes apply to all categories of E/M services? No. The E/M code and guideline changes are specific for office and other outpatient visits and apply only to codes 99201–99205 and 99211–99215.nn21.For dates of service on and after January 1, 2021, how are the levels of E/M services provided in an office/outpatient setting determined? For dates of service on and after January 1, 2021, select the appropriate level of E/M service based on the following (you choose): The level of the medical decision making as defined for each service; OR the total time personally spent by the clinician for all services related and dedicated to that patient on the date of the encounter.nn22.Does the revised medical decision-making table for 2021 provided by the AMA apply to all E/M services? No. The CPT E/M code and guideline changes for 2021 and subsequent MDM table only apply to office/outpatient E/M services beginning January 1, 2021. All other E/M categories and codes continue to follow the 1995 and/or 1997 E/M guidelines. However, the additional clarification provided in the new guidelines displays the importance of documenting clinically significant details (medically necessary), avoiding templated checkbox information and provides definitions for many of the terms on the table of risk to help the reader understand appropriate considerations of Medical Decision Making.nn23.Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines? The approved revisions do not materially change the three current MDM elements, but instead provide extensive edits to the elements for code selection and revised or created numerous clarifying definitions in the E/M guidelines. While the provider’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level. The revised code descriptors state a “medically appropriate history and/or examination” is required.nn24.Is time defined differently for office and outpatient E/M services effective for dates of service on and after January 1, 2021? According to the AMA, for dates of service on and after January 1, 2021, time is defined as minimum time, not typical time, and represents the total encounter time personally spent by the clinician on the date of service. This definition applies only when code selection is based on time and not MDM.nIs time defined differently for office and outpatient E/M services effective for dates of service on and after January 1, 2021? According to the AMA, for dates of service on and after January 1, 2021, time is defined as minimum time, not typical time, and represents the total encounter time personally spent by the clinician on the date of service. This definition applies only when code selection is based on time and not MDM.nn25.When coding by time, is the day of encounter by calendar date or 24-hour period? When coding by time, only the time spend on the actual calendar date of the encounter is applicable.nn26.How is time counted under the CPT E/M code and guideline changes for 2021? Except for code 99211, per AMA, beginning with CPT changes 2021, time alone may be used to select the appropriate code level for the office or other outpatient E/M service codes (99202-99205, 99212- 99215). Time may be used to select a code level in office or other outpatient services regardless or not counseling and/or coordination of care dominates the service. When time is used to select the appropriate level for E/M service codes, time is defined by the service descriptors. The E/M services for which these guidelines apply require a face-to-face encounter with the clinician. For office or other outpatient services, if the clinician’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use code 99211.nn27.What activities can be counted towards total clinician time? Time includes the following activities when personally performed by the clinician:n
The reports below describe a patient undergoing a tracheostomy operation and a bronchoscopy operation. Both procedures have been documented in detail, describing the step-by-step process used by doctors to carry out each surgery. Keep reading for more on how each procedure was performed.nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. nn
OPERATIVE REPORT (2 of 2)nn
The pandemic may have negatively impacted many things, but the health industry may emerge stronger in 2021 because of Covid-19 impacts. Virtual care, clinical trials, and digital relationships between patients and physicians are a few of many areas that executives should focus on. Continue reading below to learn more about how healthcare might change or continue to improve in 2021.nnWhat will the healthcare landscape look like in 2021?nnPricewaterhouseCoopers (PwC) Health Research Institute (HRI) released its annual health industry forecast Wednesday morning detailing how the healthcare system of 2021 can be reimagined and emerge from the COVID-19 pandemic in a stronger position. While the 2020 forecast focused on returns from digital investment, M&A activity, and DEI, the top health industry issues of 2021 are likely to center around how the healthcare system will built itself back up after the struggles created by the coronavirus outbreak. Healthcare organizations saw struggles with finances, the national supply chain, staffing shortages, and staying afloat during the pandemic. According to PwC, there are opportunities for the health industry to rebound in a stronger and smarter way in 2021. “As this pandemic makes painfully visible, medicine alone—ventilators, drugs, ICUs—will not save us. Medical care contributes only 10% to 20% of positive health outcomes. Rather than facing these realities, we too often continue to reactively Band-Aid,” Dr. Mona Hanna-Attisha said during PwC’s 180 Health Forum in October. “We can’t afford to do that anymore. … Addressing the upstream root causes is the only answer … with crisis comes opportunity.”nnBelow are some key areas of the report that healthcare executives should focus on:nnVIRTUAL CAREnPwC found that over 90% of surveyed healthcare organizations are using telehealth for primary care services. Nearly 70% of those leaders said that “telehealth has been most useful for follow-up appointments. According to PwC, health leaders should “pay equal attention to revenue and customer experience” when it comes to the success of telehealth in their organizations.nnCLINICAL TRIALSnDue to the pandemic, pharmaceutical and life sciences, companies recognized that clinical trials can be conducted remotely. These companies are hoping to continue this trend by conducting trials with “few in-person interactions.” The FDA created special guidance for trial sponsors during the pandemic, and PwC stated that these changes could be here to stay. Pharmaceutical and life science executives were nearly unanimous in saying that they expect digital investments in clinical trials to increase in 2021.nnDIGITAL RELATIONSHIPS FOR PHYSICIANSnMore than 90% of executives from the provider, life sciences, and health plan sectors answered that “improving the clinician experience is a priority for their organizations as they enter 2021.” According to PwC, digital technology can help improve the physician experience. Due to the pandemic, “administrative burdens” for physicians were reduced due to relaxed rules from CMS. Some private insurers also made claims a faster and easier process, and PwC believes there will be an increase of payers’ investments in automation by 2021. Health plan executives also said that a big focus for 2021 will be on “the physician-patient relationship verses members directly.”nnHEALTHCARE FORECASTINGnAlmost three-quarters of healthcare executives said that their organizations will be investing more in predictive modeling in 2021. According to PwC, “this capability to forecast the future could be as important to healthcare survival in 2021 as a mask may be for slowing the spread.” Moving forward, healthcare executives should focus on regional forecasting and collaborating with others in their area. More than 70% of healthcare executives said they were either starting to collaborate with other healthcare organizations or had plans to, due to the pandemic. Nearly two-thirds of leaders said they were either starting to collaborate or were planning to collaborate with public health agencies.nnHEALTH PORTFOLIOSnIn 2021, PwC expects healthcare organizations to increase their investments in the “gaps exposed by the pandemic.” Hospitals and health systems who had invested in telehealth, home care, and digital capabilities that laid the groundwork for the rapid expansion of telemedicine due to the pandemic, have also “mostly recovered” from the initial hit of the pandemic. Meanwhile, organizations who are struggling financially may look into options such as M&A.nnSUPPLY CHAINnForward-looking, PwC expects there will be a transformation of the national supply chain after the pandemic revealed flaws in the current system. “In 2021, HRI expects distributors and health systems to consider establishing contracts with secondary suppliers, joining new group purchasing organizations, relocating facilities and approaching storage and distribution on a more regional scale,” the report stated. Ninety-four percent of life sciences executives and 86% of provider executives see “improving supply chain transparency” as their top priority for 2021.nnINTEROPERABILITYnAlmost a quarter of providers and health plan executives said that their organizations view the new federal rules on interoperability as a “strategic opportunity.” PwC suggests that healthcare organizations should have a “compliance-focused approach” and develop strategies for interoperability if they don’t want to be left behind. More than two-fifths of executives said that they have identified a leader to guide interoperability efforts for their organizations going into 2021. PwC also stated that consumer education should be a priority in 2021 so there is trust built between healthcare organizations. According to the report, “A comprehensive strategy that considers how the rules can lead to a more effective healthcare system that puts the consumer in the center would put the organization on offense in this new data-sharing environment.”nn nnOriginal