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Getting paid for the services

you are providing

Revenue Cycle OptimizationGinger Biesbrock PA-C MPH MPAS AACC

Sr Vice President Consulting

[email protected]

904-580-01901

mailto:[email protected]


Eligibility Processes

Patient Liability

Collections

Patient Care Management

Denials Management

Charge Capture

Appropriate Level of Care

Population Cost

Management

Revenue Cycle

Imperatives

Improve

Performance

and

Efficiency

Healthcare Reform Impacts

INCREASED

COVERAGE

PAYMENTS

CUTS

Illustration adapted from HFMA Revenue Cycle Excellence presentation on Reform Impacts

2


Revenue

Cycle

Paradigm

Shift

Historically

Back-end

Weighted

Revenue

Cycle

Front-End

Weighted

Revenue

Cycle

Pre-Service

Serv

ice

Post-Service

Post-Service

Serv

ice

Pre-Service

3


Our Shift

and Making

ProgressC

urr

en

t S

tate

Post-Service

Serv

ice

Pre-Service

• Scheduling & Pre-

Registration

• Financial Counseling

• Financial Clearance

• Registration

• Denial Prevention

• Claims Processing

• AR Management

• Payment Posting

• Denial Resolution

• Managed Care

Contracting• Charge Capture

• Health Information

Management

• Clinical Documentation

Improvement

• Revenue Integrity

4


Goals of a Pre-Service Center

• Standardized training and

delivery programs to

accommodate development

needs of staff

• Consistent policies for

workforce management

• Standardized KPIs for

improved productivity

• Process redesign across

all workflows to increase

efficiency

• Improved reporting

methodologies and

processes for increased

operational insight and

management

• Optimization of verification

and estimation software for

improve staff efficiency

• Consistent process to

ensure there is no delay to

patient care

• Standardized reporting and

metrics for effective

management

People Process Automation

Administrative processes are accomplished separate from the clinical encounter allowing focus

on the patient and the patient’s care at the point of service

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1 2 3 4 5

Charge Capture Processes to provide Reliability

Map out hospital

charge capture

processes

across locations

– develop

feedback

reporting loops

CV Coder on the

team for

education and

E/M audits –

review of small

% to assure

accuracy

CV Coder for

procedural

coding – CV

only

High end

procedures with

active review

process for each

case – pre-

submission

RE- TAVR,

LAAO, etc.

Assure

appropriate

diagnosis coding

to capture

HCCs, etc.

6


Standard Measures for Post Service

Key Performance Indicator Value Cardiovascular Standard Industry Standard

Point-of-service collections (all self pay)

Accelerates cash collections and may reduce collection costs Median - 38% Varies - average 40%

Charge Lag DaysTrending indicator of charge capture workflow efficiency - impacts cash flow. Measured from the time charge entersthe coding work queue until the time it is submitted to the claim

Average 5-7 days 10 days or less

Adjusted Collection Rate Reveals how much revenue is lost due to various factors. Average 98% 95-99%

Days in AR Trending indicator of overall A/R performance Average 35 daysBelow 50 days (30-40

desirable)

Denial Rate Effectiveness of your processes Average 5% 5%-10% (5% desirable)

Average Reimbursement Rate

Average amount the practice collects from the total claims submitted. Higher the number, better the revenue

No data available 35% to 40%

First pass yield Indicator for back-end yield from front end efforts. (Production/Quality No data available Manufacturing/Six Sigma

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Transitional Care Management (TCM)

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Assume responsibility

for the beneficiary’s care

Establish a

care plan

Communicate with

patient and/or caregiver

within 2 days

Face-to-face visit within

7 or 14 days

Appropriate complexity

of medical decision

making

What must be done?

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CPT Code Descriptions

Transitional care management

services with moderate

medical decision complexity

(face-to-face visit within 14

days of discharge); or

Transitional care management

services with high medical

decision complexity (face-to-

face visit within 7 days of

discharge).

CPT Code 99495 CPT Code 99496

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1 2 3

Requirements for TCM services include:

The health care

professional accepts

care of the beneficiary

post-discharge from the

facility setting without a

gap and takes

responsibility for the

patient’s care

Includes a 30-day TCM

period beginning on the

date the patient is

discharged from the

inpatient hospital setting

and continues for the

next 29 days

Services required during the patient’s transition to the community setting following inpatient discharge. May be discharged to patient’s home, rest home, or assisted living facility.

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WHO? Physicians & APPs (within their State’s scope of practice). Certain non-face-to-face services may be furnished by

licensed clinical staff under your direction. (Refer to Medicare’s full list of what services may be performed.)

COMMUNICATION MUST BE ITERATIVE A successful attempt requires a direct exchange of information and appropriate

medical direction. Cannot be a voicemail or email. TCM services may not bill the TCM if there was no successful contact

in the 30 days between the date of discharge and the date of service for the post-discharge TCM code.

NON-FACE-TO-FACE SERVICES You must furnish non-face-to-face services to the patient, unless determined that they

are not medically indicated. (Reason must be documented.) These services may include: Review of discharge

information; Review need or follow-up of diagnostic tests or treatments; Interaction with other health care

professionals; Education to patient and/or caregiver, etc.

FACE-TO-FACE SERVICE One face-to-face visit must be furnished within the above timeframes. (Within 7 or 14 days,

dependent on code.) This face-to-face visit is part of the TCM service and is not reported separately.

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Patient Discharged

Clinical Staff

must call or

receive a call –

within 48 hours

Follow-up visit w/

Provider within 7-

and 14- days post

discharge

13


Obtain and review discharge

information (for example,

discharge summary or

continuity of care

documents);

Review need for or follow-up

on pending diagnostic tests

and treatments;

Interact with other health

care professionals who will

assume or reassume care of

the beneficiary’s system-

specific problems;

Provide education to the

beneficiary, family, guardian,

and/or caregiver;

Establish or re-establish

referrals and arrange for

needed community

resources; and

Assist in scheduling

required follow-up with

community providers and

services.

NON - Face-to-Face Services

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Chronic Care Management (CCM)

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1 2 3 4

What is CCM?

Chronic Care Management (CCM) services by a physician or non-physician practitioner (PA, NP, CNS) and their clinical staff, per calendar month.

Includes patients

with multiple (two or

more) chronic

conditions expected

to last at least 12

months or until the

death of the patient.

Conditions place the

patient at significant

risk of death, acute

exacerbation/decom

pensation, or

functional decline.

Only 1 practitioner

can bill CCM per

service period

(month)

1 2 3 4

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Included Services

Comprehensive Care Management and Care Planning

24/7 Access to Address Urgent Needs

Enhanced Communication (for example, email)

Advance Consent

Use of a Certified Electronic Health Record (EHR)

Coordination with Home- and Community-Based Clinical Service Providers

Continuity of Care with Designated Care Team Member

**Equates to

greater than 20

minutes per

month


Add on Code G0506 – (0.87 wRVU) - will

be a code that is only billable one time,

at the initiation of CCM services.

Includes a 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

Initiating

Visit

18


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

NetworkMLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2017.pdf19

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2017.pdf


Virtual Care

20


What is Virtual Health Care?

Enables continuous, connected care via digital and telecommunication technologies

Engaging with clinicians and patients in a virtual manner to provide care and impact health includes.

Includes clinician or provider non-facing solutions such as virtual consults and virtual second opinions.

The overall goal is to improve access to critical services and reduce cost constraints across the continuum of care

21


Overall Size &

Geography

Patient Population

& Mix

Value-Based

Reimbursement

Services to Offer Technology

Program Impacts

• Enterprise

care

• Regional

Variation

• Local Delivery

•Disease case

mix

•Demographics

•Payer

population

• Inpt/Outpt mix

• Primary Care

• Specialty

• Unique

• Concierge

•Availability

•Cost/Funding

•Data

governance

•Quality

•Projections 3

to 5 years

•Cost efficiency

considerations

22


Considerations for “virtual telephone visits”May serve as a virtual follow-up visit following a previous in-person visit

May involve counseling, patient education, and consent

Potential reimbursement – payer specific guidelines

Proactive versus reactive

Involves medical decision making and/or care coordination that necessitates the involvement of a provider

May involve changes in treatment plans and medications

May involve refills or adjustments of medications that would have otherwise necessitated a visit

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Service CPT Code wRVUsNon-Facility

Estimated Fee

Facility

Estimated FeeCPT Guidance

Virtual Check In G2012 0.25 $14.78 $13.33

• Established patients

• Cannot originate from a related EM within the previous 7 days

• Cannot leading to an EM or procedure within the next 24 hours or

soonest available appointment

• 5-10 minutes of medical discussion

• Require patient consent prior to performing and billing the service

Remote Eval of Pre-Recorded

Video/Images Established PtG2010 0.18 $12.61 $9.37

• Established patients

• Follow-up with the patient within 24 business hours

• Cannot originate from a related EM within the previous 7 days

• Cannot leading to an EM or procedure within the next 24 hours or

soonest available


Interprofessionnel

telephone/Internet/EHR management

(consultation)

99451 0.70 $37.48 $37.48

• Time Based Codes

• New or Established Patients

• Billed by practitioners that can bill E/M services

• Require written report to treating/requesting provider

• Consultant should not have seen the patient in a face-to- face

encounter within the last 14 days

• The written or verbal request for by the treating/requesting provider

should be documented.


99452 0.70 $37.48 $37.48

Remote Physiologic Monitoring

Treatment Management Services

99453 Practice

Expense Codes

Only

$19.46 Practice

Expense Codes

Only

• Device used must be a medical device as defined by the FDA

• 99453 may be used to report the set-up and patient education on

use of the device(s).

• 99454 may be used to report supply of the device - each 30 day

• 99457 report once each 30 days regardless of the number of

parameters monitored.

• 99457 Requires 20 minutes or more of clinical staff/ physician/other

qualified health care professional time in a calendar month.

99454 $64.15

99457 0.61 $51.54 $32.44

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Not “new” codes

for 2019

Activated as

separately

billable and

reimbursable

Accounts for

time before or

after EM visit

time – BEYOND

the usual time =

PROVIDER time

Strictly defined

time

requirements

must be met

Non-Face-to-Face Prolonged Services

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1 2

CPT Codes

Prolonged evaluation and

management service before

and/or after direct patient care,

first hour

Prolonged evaluation and

management service before

and/or after direct patient care, for

each additional 30 minutes (listed

separately in addition to the code

99458)

99358 99359

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Provided same day

as an EM or

different day

ONLY provider time

counts and related

and a part of on-

going management.

Some of the Rules

Time does not have

to be continuous –

remember

EXTENDED TIME

Time starts after the

typical time

associated with the

visit being billed.

Can not count time

related to review of

your own records or

notes.

Cannot be billed

with CCM or TCM.

27


Example of Typical Time

CPT code Typical EM Time Threshold 99358Threshold for

99358 and 99359

99203 - New Pt. 30 minutes 60 105

99204 - New Pt. 45 minutes 75 120

99205 - New Pt. 60 minutes 90 135

99213 - Est Pt. 15 minutes 45 90

99214 - Est Pt. 25 minutes 55 100

99215 - Est Pt. 43 minutes 70 115

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Recommended Documentation

Information regarding the duration and content of the medically necessary

evaluation and management service and prolonged services billed is required in

the medical record

The medical record must be appropriately and sufficiently documented by the

physician or qualified NPP to show that the physician or qualified NPP

personally furnished the direct face-to-face time with the patient specified in the

CPT code definitions

The start and end times of the visit should be documented in the medical record

along with the date of service

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Risk Adjusted Coding

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Three tools to improve

documentation

Evaluate the Current State

Education and Buy-In

Accurate Retrospective Coding

31


Step One: Evaluate the Current State

What does your

documentation look like now?

Where are the gaps in

capturing the specificity of the

diagnosis code (ICD10)?

Are providers capturing

complete historical and

chronic disease information

on their patients that impact

their condition(s)?

Are documented specific ICD

10 diagnosis being “billed” on

claims?

Are workflows sufficient to

capture all relevant HCCs?

1

32


Step Two: Education and Buy-In

Continually invest in

documentation and

coding education.

Monitor coding through

regular internal audits

Create a solid CDI

program and query

process.

Review CMI monthly to

stay on top of changes.

Review length of stays

for your DRG’S

2

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Step Three: Accurate Retrospective Coding

Minimize rework by utilizing clinical

EMR workflows. Should not be time

consuming for providers.

Provide downstream feedback to

facilitate improvement.

Implement accurate coding

processes across the continuum of

care – establishes a comprehensive

process to accurately capture HCCs.

Monitoring and analysis of ongoing

claims and patient baseline RAF

scores.

3

34


Take Away

Reconcile cases and dates of service.

Review coding and billing data.

Identify areas of

improvement.

Review areas of progress and areas to

target.

35


SpecificityIf you mean….. Don’t say

Chronic obstructive asthma w/acute exacerbation COPD

Hypertensive heart disease w/ heart failure Heart failure, LV Hypertrophy/Hypertension

Lung cancer with metastasis to liver Lung cancer/Liver cancer

Alcohol dependence Alcohol abuse

Morbid Obesity with a BMI of 45 Obese

Peripheral vascular disease of right lower ext with

claudication

PVD

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Q&A Ginger Biesbrock PA-C MPH MPAS AACC

Sr Vice President Consulting

[email protected]

904-580-0190

37

mailto:[email protected]

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