To successfully transition to value-based care, health systems must engage their physicians in the process.nnFiguring out the best way to engage physicians, however, is often one of the toughest challenges for organizations as they move from traditional fee for-service (FFS) models to models based on the efficient delivery of high-quality care.nnPhysicians drive the bulk of utilization decisions that influence health outcomes, which is one reason their buy-in is critical for transforming care delivery. Success in this new model requires physicians to adapt to a new way of practicing medicine, as well as to adjust to a new compensation model that rewards clinicians for providing high-quality care and containing costs, rather than on the volume of care provided.nnThe transition may be particularly tough for primary care physicians (PCPs) who are now called to serve as care quarterbacks. In this new world, PCPs will be tasked not only with serving the patients in front of them, but also starting to manage entire patient panels outside of the four walls of their clinics. Unfortunately, physicians are not always prepared to take on these additional tasks and must first overcome a number of systemic hurdles.nnUnderstanding current hurdlesnHealth systems attempting to engage physicians in the transition to value should be cognizant of factors that add to the challenge. For example, until recently most physicians have not been educated on the principles of newer care models based on the delivery of cost-effective outcomes, nor on population health management. Only now are medical schools beginning to incorporate these subjects into their curricula—but the impact remains to be seen. They also must address the ongoing challenge of how to influence physician behavior during the gradual shift away from FFS. Because physicians are still mostly paid on a fee-for-service basis, rather than for coordinating care and quality improvement, they have remained focused on providing more services that drive higher reimbursements.nnPhysicians must also adapt to new care coordination requirements. Traditionally no one provider has been responsible for tracking a patient’s care across all provider types and care settings. What makes it even more challenging is that technologies were not built to support this effort—they were built to sustain the FFS model. Physicians haven’t had to worry about financial penalties for duplicating care, nor for missing opportunities to improve patients’ health. Furthermore, physicians have lacked technologies to help advance care coordination efforts because legacy IT systems were designed primarily to support FFS billing functions and lack interoperability. Value-based care models, however, require PCPs and their care teams to manage care more effectively.nn
In addition, the pressure of these many hurdles is magnified for PCPs because of the historical undervaluation of their services in comparison to their specialist counterparts – despite the complexity and variety of conditions seen in primary care. Meanwhile, physicians are overburdened with regulatory and administrative requirements that squeeze them financially and reduce the amount of time spent on patient care. Attempts by payers and purchasers to enforce value-based behaviors using diverse metrics and proprietary programs add to the overload – particularly if physician compensation is not properly aligned. With all these pressures, it’s little wonder that physicians are experiencing widespread career dissatisfaction and burnout.nnTaking a programmatic approach to drive changenGiven all these challenges, how can a health system successfully engage physicians in value-based initiatives? Ideally organizations should adopt a holistic, prescriptive methodology that is supported by people, processes and technology and strives to achieve the Triple Aim plus One – that is, improved clinical outcomes, lower costs and higher patient satisfaction, plus better physician engagement.nnTo successfully engage physicians and drive change, consider this programmatic approach:n
In the 2019 proposed rule on the Medicare Physician Fee Schedule (PFS), the Centers for Medicare and Medicaid Services (CMS) proposed revisions to the E/M documentation guidelines intended to reduce administrative burden on physicians. In addition, the federal CMS proposed coding and payment changes to new and established office visit services. The AMA led the development of a joint comment letter from 170 physician and other health professional organizations calling for the agency to finalize several proposed changes to E/M documentation guidelines for CY2019.nn“The AMA is pleased to report that the federal CMS is implementing the documentation policies, which will significantly reduce administrative burden and allow all physicians to spend more time with their patients,” the AMA stated. The agency has also acknowledged the work of the AMA’s CPT/RUC Workgroup on E/M and has postponed any coding and payment-related changes for E/M office visit services until CY2021. This delay in implementation will allow the CPT Editorial Panel to consider the workgroup’s proposal in February 2019 prior to prompt consideration by the AMA/Specialty Society RVS Update Committee (RUC).nnOn page 584 of the rule, the federal CMS states:nn“We recognize that many commenters, including the AMA, the RUC, and specialties that participate as members in those committees, have stated intentions of the AMA and the CPT Editorial Panel to revisit coding for E/M office/outpatient services in the immediate future. We note that the 2-year delay in implementation will provide the opportunity for us to respond to the work done by the AMA and the CPT Editorial Panel, as well as other stakeholders. We will consider any changes that are made to CPT coding for E/M services, and recommendations regarding appropriate valuation of new or revised codes.”nnRemoving restrictions on E/M codingnnThe federal CMS finalized several changes to E/M documentation guideline which were strongly supported by the AMA and other members of the federation.n
1995 or 1997 Evaluation and Management Guidelines for history, physical exam and medical decision making (current framework for documentation).
CMS has proposed to reward physicians who consult electronically/by phone with other physicians in 2019. The agency also proposed starting to pay physicians to review photos that patients text/e-mail to them. Telehealth is now playing a new role for appropriating medical services and giving providers the helping hand to create connected care platforms!nnUnderstand Medicare telehealth requirements—including coverage, coding, and documentation rules—and ensure your telehealth program and claims comply.nnBank on TCI’s all-new, end-to-end 
As many of us reflect on the things in life we are thankful for, all of us at Welter Healthcare Partners would like to say Happy Thanksgiving to our clients, business partners, families and friends! We are extremely grateful for each of you and appreciate your continuous support!nnIn observance of the holiday, we will be closed on Thursday, November 22nd to give our employees time to enjoy the day with their loved ones. We hope you have a wonderful Thanksgiving!nn2019 CPT Changes
Written By: Toni Elhoms, CCS, CRC, CPC, AHIMA-Approved ICD-10-CM/PCS TrainernDirector of Coding/Compliance nn
It’s that time of the year again! The new 2019 CPT code changes took effect January 1st. Understanding the myriad of upcoming changes is crucial to obtaining the proper reimbursement for your services! The changes for 2019 address a number of interrelated issues. The AMA updated 335 codes to reflect scientific and technological advances in various services including medical, surgical, and diagnostics. Several additions reflect the real possibility of expanding coverage for connected health tools and other new delivery systems to improve healthcare quality. There were many code revisions with guideline, description and instructional note changes. CPT 2019 offers changes that affect nearly every specialty.nn*Please note, this article is not an all-inclusive list; review your 2019 CPT book for complete descriptions of all changes. Appendix B of 2019 CPT provides a summary of additions, deletions, and revisions. — Click here for more informationnnAlso, CLICK HERE to review the final rule for the 2019 Medicare Outpatient Prospective Payment System (OPPS).nnHighlights of the most significant changes:n
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- Exciting new opportunities for telemedicine expansion and coveragen
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- These new codes reflect the key role non-verbal communication technology plays in care coordination between consulting and treating physicians, according to the AMA.
- CMS will pay for 2 newly defined physicians’ services furnished using communication technologyn
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- HCPCS Code G2012 – Virtual Check-In
- HCPCS Code G2010 – Remote Evaluation of recorded video and/or images submitted by an established patient
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- 3 new codes for remote chronic care patient monitoring servicesn
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- New CPT codes 99453 and 99454 should be used to report remote physiologic monitoring services during a 30-day period.
- CPT code 99457 requires live, interactive communication with the patient/caregiver and 20 minutes or more of clinical staff/physician or other qualified health care professional time in a calendar month.
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- 2 new interprofessional internet consultation codesn
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- New codes 99451 and 99152 should be used to report assessment and management services. The codes are based on medical consultative time.
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- 2 new codes added to the Ophthalmology CPT sectionn
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- CPT 92273 should be used to report global response of photoreceptors of the retina
- CPT 92274 should be used to report photoreceptors in multiple separate locations in the retina and macula
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- Revisions and Additions to FNA and skin biopsy codesn
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- CPT codes 11102-11107 should be used to report skin biopsies based on method of removal including tangential (shave, scoop, saucerize, curette), punch and incisional.
- Fine needle aspiration (FNA) codes received new instructional updates including the clinical distinction between a fine needle aspiration and a core needle biopsy. Imaging guidance is now inclusive to the nine new codes. Guidelines also instruct that codes are selected based in guidance (included) and add on-codes are appended for each additional lesion.
- CPT codes 10005-10012 were added to report the specific imaging guidance (ultrasound, fluoroscopic guidance, CT and MRI).
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- Revisions and Additions to psychological and neuropsychological testingn
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- 8 CPT codes 97151-97158 and guidelines were added to Adaptive Behavioral services to address deficient adaptive behaviors.
- New guidelines and new CPT codes were added to the Central Nervous System Assessments/Tests including 96112 and 91113 for developmental test administration based on time. CPT add on code 96121 for a neuro behavioral status examination for ab additional hour was added. Under Testing Evaluation Services CPT codes 96130-96133 were added for neuropsychological testing evaluation services based on time.
- CPT codes 96136-96139 were added to report psychological or neuropsychological report testing and scoring. Codes are based on time and whether the service was performed by a technician or clinician. CPT code 96146 is used to report psychological or neuropsychological automated testing using an electronic platform.
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- 4 new breast MRI procedures were addedn
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- CPT Codes 77046-77049
- Codes are selected based on laterality (unilateral vs. bilateral) and with or without contrast material.
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- 2 new gastrostomy tube placement codes added to define simple versus complex replacement of a percutaneous gastrostomy tube.n
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- CPT 43762 is reported for the percutaneous gastrostomy tube placement including removal without imaging or endoscopic guidance not requiring revision of the gastrostomy tract
- CPT 43763 requires revision of gastrostomy tract
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- 3 new codes for allograftsn
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- CPT Codes 20932-20934
- CPT 20932 includes templating, cutting, placement and internal fixation; osteoarticular
- CPT 20933 includes hemicortical, intercalary, partial
- CPT 20934 includes hemicortical, complete.
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nContact Welter Healthcare Partners for assistance on 2019 CPT changes.