Today’s blog is focused on the inconsistent regulatory environment faced by LTPAC Medicine in the 2017 draft CMS rules in MACRA/MIPS and the Physician Fee Schedule.
These inconsistencies create economic challenges for the Medical professionals serving populations dwelling in LTC settings; equally important is the missed opportunity to incent a model of care that promotes primary care in these settings.
The Draft MACRA/MIPS regulations, for the first time, embody a clear statement from CMS which differentiates a Physician’s role in caring for a patient in a Skilled Nursing Facility (Place of Service 31), versus a LTC Nursing Facility resident (POS 32). (Copied from pg. 142 of the rule)
Patients in SNFs (POS 31) are generally shorter stay patients who are receiving continued acute medical care and rehabilitative services. While their care may be coordinated during their time in the SNF, they are then transitioned back to the community. Patients in a SNF (POS 31) require more frequent practitioner visits—often from 1 to 3 times a week. In contrast, patients in nursing facilities (NFs) (POS 32) are almost always permanent residents and generally receive their primary care services in the facility for the duration of their life. Patients in the NF (POS 32) are usually seen every 30 to 60 days unless medical necessity dictates otherwise. We believe that it would be appropriate to follow a similar policy in MIPS; therefore, we propose to exclude services billed under CPT codes 99304 through 99318 when the claim includes the POS 31 modifier from the definition of primary care services.
For readers who aren’t immersed in deciphering CMS’s unique language, the draft policy creates a clear distinction in the nature of the doctor:patient relationship in the two settings:
This policy distinction doesn’t correct other long standing errors in the resource use benchmarking process (LTC residents have significantly higher annual costs than their ambulatory counterparts). However, it relies on an objective measure (the presence of a Medicare Part A payment to the SNF) as a marker to distinguish between the two populations treated by the medical professionals under Medicare Part B. This lays the foundation for future methodology with a refined acuity adjustment.
Would it be too much to hope that the draft Part B Fee Schedule would align the concepts of primary care with these MIPS proposals? Apparently so.
The draft fee schedule devotes pages 143-198 to a section titled Improving Payment Accuracy for Primary Care, Care Management, and Patient-Centered Services. In my opinion, this is the clearest policy statement CMS has ever made, via the fee schedule, of its intention to transition from encounter based care to a population management model. What it fails to do is codify that LTC Nursing Facilities are locations where residents may receive these population management services.
In the fee schedule, CMS proposes to improve, and extend, the principals of Care Management via CPT® codes. In the draft 2014 Fee Schedule, CMS introduced the concept of Chronic Care Management (CCM). This was incorporated in the 2015 fee schedule as CPT® 99490 (paid at approximately $41/month for 20 or more minutes of care). When the 2015 draft schedule was published, and again in 2016, AMDA and many LTPAC Medical Groups asked if CCM applied to residents in POS 32? It wasn’t until the March of 2016 that CMS resolved this issue by issuing a FAQ (frequently asked question).
7. Can I bill CPT 99490 for CCM services provided to beneficiaries in skilled nursing facilities, nursing facilities or assisted living facilities?
If all the CCM billing requirements are met and the facility is not receiving payment for care management services (for example, the beneficiary is not in a Medicare Part A covered stay), practitioners may bill CPT 99490 for CCM services furnished to beneficiaries in skilled nursing facilities, nursing facilities or assisted living facilities. The place of service (POS) on the claim should be the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient) as per #5 above.
That policy clarification opened a safe pathway for LTPAC medical groups and facilities to begin implementing population management strategies for the residents in all LTC settings.
This clarification about the applicability of CCM to POS 32 was forgotten when the draft 2017 fee schedule was published. This doesn’t mean that the principal of using Care Management in POS 32 is lost, it simply is overlooked as a Primary Care site.
The fee schedule proposed adopting a family of care management and care coordination codes from the AMA’s CPT® panel. In several cases, the codes were still under review, and CMS elected to implement those draft definitions as HCPCS codes. To summarize the codes in the draft rule:
Changes in Codes Available for CCM
|99487||Complex chronic care management services, with the following required elements: 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, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care
Professional, per calendar month.
|99489||Each additional 30 minutes of clinical staff time per month||0.50|
|Behavioral Health Management Codes (billed by PCP)|
|GPP1||Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements…………||1.59|
|GPPP2||Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following….||1.42|
|GPPP3||Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities…||0.71|
|GPPPX||Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month.||0.61|
|Care Planning for the Cognitively Impaired Patient|
|GPPP6||Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the physician or other qualified health care professional in office or other outpatient setting or home or domiciliary or rest home.||3.30|
|Add-on Code for initiation of CCM Care Planning|
|GPPP7||Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service (billed separately from monthly care management services) (Add-on code, list separately in addition to primary service).||0.87|
|Add-on Code to recognize extra burden of office-based care for mobility impaired|
|GDDD1||Resource-intensive services for patients for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lifts, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient evaluation and management visit (Add-on code, list separately in addition to primary procedure). (limited to office CPT® codes 99201-215)||0.48|
|Non-Face-To-Face Prolonged Evaluation & Management (E/M) Services|
|99358||Prolonged evaluation and management service before and/or after
direct patient care, first hour
|99359||Prolonged evaluation and management service before and/or after
direct patient care, each additional 30 minutes
This blog has consistently argued that the publically insured population with the highest manageable costs are those individuals who reside in long term Nursing Facilities. These are the individuals who, under current policies, are no longer able to live independently. The nursing facility is where they live, and die, unless their death occurs during one of their frequent hospital stays. The vast majority of these individuals enter LTC nursing facility beds (Place of Service – POS32) following a Skilled Nursing Facility episode of care (POS 31).
The definitions CMS uses for these CPT® or HCPCS Codes come directly from the AMA current or proposed narrative CPT® descriptions. The AMA evaluates draft copies of CPT® codes proposed by its members – and these codes were created for Office based medicine. This isn’t to blame the AMA, their objective is to represent the interests of Physician Members – not CMS. Nowhere else but in nursing homes can the same individual, in the same physical location (room & bed) be:
· in a Part A post-acute episode of care during the day, and
· become a LTC outpatient with the updated midnight Census report.
This illogical dual identity for nursing homes didn’t exist in the earliest days of Medicare. We had separate Skilled (SNF), and Intermediate Care (ICF) nursing facilities. The Part B payment rates were lower because the SNF was cost reimbursed, which could include services to support the attending Physicians. The ICF had higher Part B Physician fees in the absence of the CMS facility payments.
When a patient exhausted their Medicare Part A coverage, they either went home or moved to an ICF Bed. This physical relocation was often disruptive and caused unnecessary suffering for the most vulnerable individuals. However, it was simple to keep track of the type of bed the individual occupied.
Patient Advocates successfully lobbied for the right of a patient to remain in familiar surroundings, and the concept of ‘dually licensed’ beds arose, this was in the 1980s. Physician CPT® coding, and reimbursement didn’t get corrected until 2006.
That’s the year when AMDA’s efforts to petition to the AMA and CMS for a new payment model bore fruit. The AMA approved new CPT® codes (99304-99318), and the CMS adopted a single uniform payment rate for those codes in POS 31 and POS 32. The logic that supported the unified payment rates for POS 31 and POS 32 was based on the elimination any extra services for physicians when SNF Part A moved from a Reasonable Cost Reimbursement payment scheme to the Prospective Payment System (RUGS rates).
It is possible to use the AMA as a vehicle to create a POS 32 specific payment model for Primary Care.
Developing a LTC Nursing Facility Care Management family of CPT® codes through the AMA would require a member organization (i.e. AMDA) to submit a validated study of the work physicians are performing that is not covered by existing CPT® codes. That is the best long-term solution, but doesn’t solve the problems LTPAC Medical Groups face today trying to implement population management. CMS also has a problem – it wants to support a switch to these new payment models for Primary Care.
Primary Care Physicians, and Nurse Practitioners, serving LTC Nursing Facility residents are the best available clinicians to operate a ‘treat in place’ model. Those models of care can minimize avoidable hospitalizations, improve the individual’s quality of life, and conserve resources. There are nearly $2 Billion of savings (in 2005 $s) available through improving the hospitalization rates of the Medicare-Medicaid population residing in LTC nursing facilities.
Anyone interested in address this problem should register a public comment on the draft rule asking CMS to extend its policy of covering CPT® 99490 in POS 32 to the new Care Management Codes (99487, 99489, and GPPP1-GPPP7).
If LTPAC Medical Groups are financially responsible for the Resource Use of this population as Primary Care Providers, they need a full set of management tools. The opportunity to achieve the goals of the CMS triple aim far outweighs the importance of the AMA’s CPT® development process.
By now most of the healthcare community is familiar with the term Hospitalist. It was first coined in 1996. The earliest use of the term SNFist seems to be in a 1999 NEJM article. The name refers to a Physician or other Medical Professional who specializes in treating the residents of LTPAC institutions. Many of the clinicians who belong to the American Medical Directors Association would likely self-identify as a SNFist (although the word itself lacks any poetic qualities).
The question at hand – are there large enough numbers of Physicians, Nurse Practitioners, and Physician Assistants who practice predominantly in LTPAC to justify a special designation?
A Specialty Designation is part of a physician’s identity for Medicare Billing as opposed to a Board Certified Specialty (e.g. cardiologist). The designation becomes important when CMS compares Physicians to each other – it helps to more accurately identify patterns of practice based on a care delivery model.
This question has some immediacy following the Society of Hospital Medicine’s successful petition to CMS for a Hospitalist specialty code. There are 48,000 clinicians who self-identify as Hospitalists, how does LTPAC Medicine compare? That was a frequent question at #AMDA2016.
THEREFORE BE IT RESOLVED, that AMDA - The Society for Post-Acute and Long-Term Care Medicine initiate efforts and work with the Centers for Medicare & Medicaid Services (CMS) to seek full recognition of post-acute and long-term care medicine as a medical specialty.
Geriatric Practice Management, my organization, built a CMS data set that provides some insight into the practice of LTPAC Medicine (based in part on 2012 - 2014 Part B claims).
The following table shows three years of values for Clinicians who delivered any face-to-face encounters in the SNF/NF setting.
As an initial observation, the total number of Clinicians doing any SNF/NF care is steady (about 47,000). However, the amount of care (as measured by Evaluation and Management Encounters – CPT® 99304-318) is growing at a 7-8% annual rate. What is happening appears to be a trend towards a concentration of care in the hands of clinicians who spend most, or all, of their time in the nursing facility setting.
This concentration of care is something that our colleagues in practice management, and AMDA’s regulatory affairs department predicted: the complexities of the PPACA, and the associated payment rules, are likely to discourage community and hospital based clinicians from covering LTPAC. What’s gratifying is that a slightly greater number of clinicians are electing to concentrate on Nursing Home Care.
The segmentations in the table (100% Nursing Facility, 50-99%, and <50%) were chosen for clarity, and to reinforce some important points about the Meaningful Use, Value Based Purchasing, and MIPS programs.
Clinicians who are 100% SNF/NF have a very limited set of quality measures available – even a small sampling of Assisted Living Facility residents (also part of LTPAC) opens a larger set of quality measures with more favorable bench marks. Understanding that 30% of all SNF/NF care is given by clinicians who do nothing else can bolster the industry’s arguments about restrictive options.
There are endless ways to slice-up the data. If we liberalize the definition of 100% SNF/NF to include residents in Assisted Living/Adult Home locations, the new definition becomes 100% LTPAC clinicians. Their head count then increases from 8,038 to 10,472. This is probably a much better number because many LTC facilities include nursing home and assisted living beds on the same campus.
T The 50% threshold is important – it’s the lower limit for accessing the Meaningful Use, and ACI (Advancing Clinical Information) EHR Hardship exemptions. When 70% of all care is delivered by clinicians who are eligible for that exemption, perhaps it’s time for CMS/ONC to rethink how they structure the EHR program to encourage the LTPAC Facilities to support those Clinicians use of technology. An exemption is much better than a penalty, but does little to advance patient care.
In the final analysis it seems apparent to us that there are a significant number of Medical Professionals who specialize in LTPAC. Does it make sense to seek a Medicare Specialty designation for billing and cost (resource use) measurement?
Up through the #AMDA2016 conference, we supported this wholeheartedly. However, during May, CMS published a whitepaper titled CMS Patient Relationship Categories and Codes. This proposal, mandated by MACRA, directs CMS to establish a methodology for associating Physicians and Practitioners with Medicare Beneficiaries. The purpose is to establish a more nuanced determination of the billing entity’s responsibility for both Resource Use and Care Episodes.
If CMS implements these Relationship Categories and Codes for billing, the use of a SNFist Specialty Billing Code will be a crude tool of minimal value. Of course, the corollary is that the physician, or their billing team, has to select a new code for each encounter/episode and include it on the bill. Does this sound like revisiting the pain of delivering ICD-10 to your claims?
In the months to come, we’ll post new insights into the Part B Claims data. If readers have specific topics they are interested in, please let us know.
Are you prepared for MIPS? Join me for part 2 of our 4-part webinar series: Demystifying MIPS: The Regulatory Landscape for LTPAC Medical Providers
Hello All -
We are making a few changes to the blog. Click here, to view the February Blog: 2016 PQRS Measures for use in LTPAC Medicine, Part 1
This post analyzes how regulatory changes embodied in the 2016 Fee Schedule affect LTPAC Medical Groups. The blog’s title is an accurate synopsis. Only those who believe suffering builds character will find comfort in 2016.
Back in April, a Whitehouse press release celebrated the passage of MACRA (The Medicare Access and CHIP Reauthorization Act): “At last, the doctors who care for seniors and many Americans with disabilities will no longer have to worry that about the possibility of an arbitrary cut in their pay.”Read more: LTPAC Medicine's shabby treatment in the 2016 Medicare Physicians Fee Schedule.