We want to thank all of our clients and business associates for your continued support, generosity, and trust in our company. Thank you for allowing us to serve you this most challenging year and we look forward to serving you in the years to come.
Despite the ups and downs of 2020, we all have pulled together, and gotten through it. We move into 2021 with great aspirations and hopes for all of us. We look forward to our continued relationships and wish you and your families a Very Happy New Year with good health, & much success and happiness.
Happy New Year, Your partners and friends at Advantage Medical Billing Solutions!
Linda J Sacco, Founder & CEO
This year we have some rather important changes to be aware of. For some of you this will affect reimbursements and for all of you it will affect documentation. See below for the major changes:
Elimination of the History (H) and Physical Exam (PE) as elements (providers should perform a “medically appropriate history and/or examination” there will be NO required level of history or exam for 99202-99215.
Clinicians can now choose whether MDM or Time documentation can determine the appropriate E/M Code
MDM Modification 3 MDM subcomponents remain the same but there are extensive edits to elements for code selection.
Deletion of CPT Code 99201
Shorter Prolonged Service Codes, the definition of time is minimum time, not typical time and represents total physician/QHP time on the date of service (see below for what is included in time)
The care team may collect information and the patient or caregiver may supply information directly (by portal or questionnaire) that is reviewed by the reporting physician or other QHP
Physician or other QHP includes, preparing to see the patient including review of tests, obtaining/reviewing separately obtained history, performing medically appropriate exam/eval, counseling/education to patient/family/caregiver, ordering meds, tests, or procedures, referring and communicating with other health care professionals, documenting clinical info in EMR or other Health record, independent interpretation of results and communication of results to patient/family/caregiver, and care coordination.
Some new/revised key codes to add to your EMR and be aware of how to use them:
99415 Prolonged Clinical Staff Service direct patient contact with physician supervision. First Hour, note it doesn’t have to be continuous
99416 Prolonged Clinical Staff Service direct patient contact with physician supervision. Each Addl 30 minutes, it doesn’t have to be continuous
99417 Prolonged OV E/M service total time with or without direct patient contact each 15 minutes to be used ONLY with 99215 or 99205
99358 Prolonged Services Code w/o Direct Contact first hour regardless of POS
99359 Prolonged Services code w/o Direct contact first hour regardless of POS addl 30 mins
99354-99357 Prolonged Service Codes with Direct contact for physician or other QHP for Inpatient or Observation setting beyond the usual time.
We understand this may appear confusing; however, it’s extremely important that you understand how to use these codes in your practice; your revenue depends on it.
The most important thing to understand is documenting all of the pertinent medical information but now it’s also important to document start and stop times, time used consulting, time spent on the phone with family, caregivers and patients, time spend reviewing records etc.
You know the old saying “time is money”, well in this case it really is, so we are asking that you be mindful in your code selections. You will be using a combination of codes you may not have used before and you will need to document why.
Sit down with your staff and office manager and determine how this can be done if you haven’t done so already. For those of you who are clients feel free to reach out to us if you have any questions. As always we will be looking at your notes to insure that times are documented and code selection is correct based on the notes.
Have a Safe and Healthy 2021! Wishing you the best, Linda
What is MACRA? Presently providers are reimbursed on a fee for service basis. Fees that are determined by the SGR formula or Sustainable Growth Rate. MACRA (Medicare Access and CHIP Reauthorization Act) CHIP (Children’s Health Insurance Program) bottom line is the government wanting to reimburse providers based on their quality of care, not quantity. Physicians will no longer be reimbursed based on volume of patients but on the value of care.
MACRA’s implementation will begin in 2019 but will be based on the reporting year 2017. So, even though implementation is a few years down the road the data used to determine a providers fee schedule will be based on what is reported in 2017 which is only a few months away. MACRA will allow each provider to have an individual fee schedule based on performance. Under MACRA providers will have two options:
Option 1: MIPS or Merit Based Incentive Payment System. MIPS combines parts of PQRS, VM, and HER incentive program into one program. Most physicians will be reimbursed based on MIPS.
Option 2: APM or Alternative Payment Model. APM provides ways to pay health care providers for the care they give to Medicare beneficiaries by sharing the risk. Accountable Care Organizations (ACO’s), and bundled payment models are examples of APMs. From 2019-2024 health care providers that qualify for APMs will receive a lump-sum incentive payment.
There are four components of MIPS:
1. Quality – PQRS (50%)
2. Advancing Care Information (ACI previously known as HER/meaningful use) (25%)
3. Clinical Practice Improvement Activities (CPIA) (15%)
4. Resource Use (10%)
MIPS defines the financial impact on providers by creating a composite score for each provider. The composite score will be between 1 and 100 and based on the 4 components above. Composite scores will be posted on a CMS public website known as Physician Compare.
Providers not reporting PQRS measures now receive a 2% penalty. Once MACRA is implemented PQRS could have a big impact on a providers reimbursement as the PQRS portion of the score is 50%.
Currently meaningful use is an all or nothing program. Under MACRA, MU or ACI it will no longer be all or nothing. Under MACRA ACI will account for up to 25% of a providers composite score, the provider will receive credit for the amount of MU they demonstrate. The higher the providers composite score the more they will be reimbursed for services provided to Medicare beneficiaries.
It is important for providers to prepare NOW so that their reported information in 2017 will not hurt their income in 2019. Many providers are still not reporting through the PQRS system or demonstrating MU. The current penalty does not impact them enough to make a difference. With MACRA PQRS and MU will count for up to 75% of the composite score and won’t be as easily ignored.
It is imperative for providers to exercise financial prudence and start preparing now so that you’re not surprised in 2019 when revenues are harshly impacted.
And…as always Take Advantage for all your medical billing needs.
Orthopedist Michael Reilly believes the surge of doctors going to work for hospitals is not a healthy trend. He had a firsthand view of what can happen