The Georgia Academy supported this day-long event and was a Gold Sponsor of this initiative.
Several emerging trends in health care and health care delivery that may have an impact on primary care workforce training initiatives were discussed. These included:
The Georgia Academy serves on the Steering Committee for the Primary Care Summit and will continue to work on these issue throughout the year, as well as, support legislative initiatives next winter.
Steve Adams, MCS, COC, CPC, CPMA, CPC-I, PCS, FCS, COA
This article will outline the three things we need to see in your documentation when billing a preoperative medical evaluation:
1. Reference to the request for a preoperative medical evaluation
2. The specific medical condition you were asked to address during the preoperative evaluation (e.g. from a cardiovascular or respiratory standpoint); and
3. Proof that you have returned your opinion and advice to the requesting provider.
Prior to 2001, most Medicare carriers were denying preoperative medical evaluations, both examinations and diagnostic tests, on the grounds that they were “routine physical checkups” and thus excluded from Medicare coverage by law. Even carriers who did not deny payment on this basis had conflicting policies about which ICD-9 codes should be used for these claims. Some required physicians to use one of the V codes for preoperative evaluations, some required the codes for the reason for surgery, and still others accepted only codes for comorbid conditions (e.g., hypertension) that necessitated a physician evaluation.
The purpose of this article is to clarify what the central billing office is requesting from our providers. Medical preoperative examinations and diagnostic tests done by, or at the request of, the attending surgeon should be paid, assuming, of course, that the insurance carrier determines the services to be “medically necessary.”
All such claims must be accompanied by the appropriate ICD-10 code for preoperative examination (i.e., Z01.810 – Z01.818). Additionally, you must document on the claim the appropriate ICD-10 code for the condition that prompted surgery. If there are other diagnoses and conditions affecting the patient, you should also document those on the claim.
Putting It All Together
Let’s say an ophthalmologist requests a preoperative clearance from you for a patient who has diabetes and hypertension and is scheduled for cataract surgery, right eye.
You document the requesting provider’s name and the reason for the preoperative medical evaluation. Then you perform an evaluation and management service and forward a copy of your findings and recommendations to the ophthalmologist clearing the patient for surgery.
When you bill for this service, the primary diagnosis on the claim, and the one attached to the EM code on the line item, will be a Z code (e.g., Z01.818, “Encounter for other preprocedural examination”).
The secondary diagnosis will be the reason for the surgery, the cataract in the right eye (e.g., H25.031, “Anterior subcapsular polar age-related cataract, right eye”).
Finally, if appropriate, you would also code the patient’s diabetes (e.g., E11.9, controlled, type 2 diabetes) and hypertension (e.g., I10, hypertension, benign).
The Medicare Shared Savings Program (MSSP), established by the Patient Protection and Affordable Care Act of 2010, offers a new path in healthcare delivery and aims to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries while reducing unnecessary costs. The MSSP seeks to accomplish these goals through facilitating coordination and cooperation among healthcare providers. Family physicians can voluntarily participate in the MSSP by creating or participating in an Accountable Care Organization (ACO). Many members of the Georgia Academy of Family Physicians have already joined ACOs and are now looking at either terminating their memberships or switching to different ACOs.
ACOs are groups of physicians and other healthcare providers who choose to work together with Medicare to provide medical services to FFS beneficiaries. If beneficiaries receive at least one primary care service from a physician within an ACO, beneficiaries will be assigned to an ACO. In addition, ACOs must have a minimum of 5,000 FFS beneficiaries assigned to ACO participants. Therefore, it is very difficult and can even be impossible for some small group practices to meet the requirements to participate in an ACO. An ACO’s assigned population also cannot fall below 5,000 FFS beneficiaries at any time during the performance year.
A significant distinction in how the MSSP treats primary care practices and specialized medical practices is in the number of ACOs a physician practice can join. A primary care physician is restricted and can only join one single ACO; CMS rules do not limit the number of ACOs that a specialist may join, however.
While the MSSP has established goals it hopes to meet through ACOs, Academy member physicians are experiencing uncertainty regarding how successfully these goals will be met. As a result of the restrictions placed on primary care physicians participating in ACOs, as well as the difficulty some ACOs have in meeting (or continuing to meet) the CMS rules, family physicians should keep the following principles in mind when contracting with ACOs:
1) The contract should allow the family physician to terminate without cause after a certain number of days. This will allow the physician to switch to a different ACO;
2) The term of the contract should be for no more than two years, as ACOs will likely encounter difficulties that may encourage the family physician to switch to a different ACO;
3) The contract should carefully follow the parameters of the ACO rules and not include extraneous terms to the ACO;
4) The contract should describe the compensation methodology in detail (if it does not, the family physician should request the distribution policy from the ACO);
5) The contract should not include a non-compete or any other restrictive covenant that would limit a family physician from joining another ACO; and
6) If this is the first contract that a family physician contemplates signing, he or she should have an attorney review the contract for all the other, non-ACO related provisions.
As ACOs enter their “second generations”, many Academy members will become comfortable with contemplating membership in an ACO. Whether the family physician is looking at terminating or changing ACOs, or joining an ACO for the first time, the Academy member should carefully review the participation contract to ensure that it follows the ACO rules and allows for mobility if the ACO arrangement is not productive.
Richard Sanders, Esq. is a partner in The Sanders Law Firm, P.C. in Atlanta. He can be reached at (404) 806-5575 or firstname.lastname@example.org.
Dear Georgia Academy of Family Physician Members,
It’s my pleasure to share that Georgia Academy of Family Physicians is partnering with the Consortium for Southeastern Hypertension Control (COSEHC) and the American Board of Family Medicine, both recipients of the CMS Transforming Clinical Practice Initiative (TCPI) grant. QualityImpact, the COSEHC Practice Transformation Network (PTN) along with the ABFM’s PRIME Support and Alignment Network (SAN), will serve providers in the Southeastern U.S. over the next four years in preparing them for new payment models and MACRA.
Practices that enroll in the QualityImpact PTN will receive a comprehensive, transformation “package” at no cost that includes:
·MDinsight – A sophisticated, interoperable population health management platform
·Care Delivery Consulting – Process improvement facilitation enabling improved efficiency, quality, and proactive patient management
·Clinical Quality Improvement – Expert-led guidance tailored to care gaps/opportunities
To this package, the ABFM PRIME SAN is adding, at no cost to PTN enrollees:
·PRIME Registry free for 3 years to 6,000 ABFM board-certified Family Physicians-the first family medicine specialty registry, also open to your primary care colleagues. PRIME is a qualified clinical data registry (QCDR) allowing you to submit for PQRS and MACRA/MIPS and APMs to come, qualifies for Meaningful Use Objective 10, and currently supports more than 90 EHRs and 42 electronic clinical quality measures
·Maintenance of Certification-FP Part IV credit for each year you are enrolled in a PTN
·Collaborative CME learning sessions at the annual Family Medicine Experience (FMX) conference highlighting TCPI learnings and best practices
PHEW – That’s a lot of accronyms related to how this project will work.
Bottom line – we want you to consider enrolling in the COSEHC practice transformation network AND the American Board of Family Medicine’s Support and Alignment Network. The GAFP leadership believes strongly – that this will provide you and your practice with a tremendous amount of practice management and clinical support.
CMS’s message is clear: value-based reimbursement is coming, whether we’re ready or not. As an organization, we recognize the significant challenges our colleagues will face in this transition. QualityImpact and ABFM PRIME, through the Transforming Clinical Practice Initiative, present a tremendous opportunity to receive support and resources to enable your success.
The PTN is onboarding providers on a first-come, first-serve basis. I encourage you to visit qualityimpact.org or contact Debra Simmons, the PTN Program Director (email@example.com, (336) 716-1130) to learn more. I also encourage you to visit https://www.theabfm.org/primeregistry/primesan.aspxor contact Dr. Elizabeth Bishop, the PRIME SAN Program Manager (firstname.lastname@example.org) to learn more about their additional benefits.
Both of these groups will be at our Summer CME meeting in Hilton Head – June 10th and 11th. We believe this is a “two-for-one” opportunity that you and your practice colleagues need to join before the recruitment spots are filled.
Mitzi B. Rubin, MD, FAAFP
GAFP Chapter President
In March, the Practice Management Committee and the Public Health Committee collaborated to design a survey that addresses member’s experience with Medicaid. The Practice Management Committee is interested in knowing how many members are accepting Medicaid patients and what issues related to Medicaid that patients and members are experiencing.
To participate in the 2016 Practice Management Medicaid Survey, please Click Here.
This webinar, hosted by MedMal Direct Insurance Company, will examine the most common areas for medical errors, review strategies to minimize risk in a medical office and explore communication techniques to manage the physician-patient relationship. MedMal Direct is the endorsed Medical Professional Liability Insurance Carrier of the GAFP, they are an admitted carrier in Georgia and exclusively offer their policies directly to healthcare providers. Direct access means significant savings for the same level of coverage, direct lines of communication with the experts, and a better strategy of defense, all from a financially strong company. If you are interested in a quote contact Paul Burnthall at 404.219.8589.
We are working with the California Academy and need your assistance with a short (three-minute) survey focused on advanced care planning and end-of-life conversations. All Georgia AFP members are encouraged to complete the survey because as part of multidisciplinary teams who care for older patients, your responses will help shape medical education in this important area. No identifiable information will be reported. Follow the link below to begin the survey. Thank you in advance for helping with this important project. Questions, contact Shelly Rodrigues at email@example.com.
Effective January 1, 2016, the Department of Community Health will implement a change to its existing physician office visits policy in order to allow Medicaid eligible members to have access to preventive health services. Members 21 years of age and older will now be able to access one preventive health visit each calendar year (CY) and 10 office visits (evaluation and management codes 99201 to 99215) each CY. The Department encourages primary care practitioners (PCPs) of the following types to perform the preventive health visits: physicians (internists, family physicians, or OB/GYN specialists), certified nurse practitioners, or physician assistants. FQHCs and RHCs may bill for these provider types performing preventive health visits within the FQHC or RHC. Additional office visits (above the 10 visits) will still be available based upon documentation and supporting medical necessity that must be sent to Alliant/Georgia Medical Care Foundation (GMCF) for review. This policy change supports the Department’s goal to improve the health outcomes of our enrolled Medicaid members by allowing them to establish a medical home and receive preventive health services. The establishment of a medical home will also support the Department’s efforts to reduce hospital re-admissions.
Providers may bill ONE (1) preventive health visit (993XX) for a member annually (between January and December of the CY). Providers must use one of the following ICD-10 diagnosis codes when billing the preventive health visit code: Z00.00 or Z00.01 (Encounter for adult examination). Each member is allowed 10 office visits (992XX) per CY without prior authorization. The following preventive visit codes are billable for this policy change:
99385 or 99395 (Adults 21 through 39 years of age). This code is currently open for members under the age of 21 years in the Health Check program (COS 600),
99386 or 99396 (Adults 40 through 64 years of age), and
99387 or 99397 (Adults 65 years and older).
The Georgia Medicaid Management Information System (GAMMIS) will be configured to align with these changes. We anticipate the configurations will be complete by the second quarter of CY 2016. Providers may begin billing for the preventive health visits in January 2016. Reimbursement will not be available until GAMMIS is configured according to the new policy. Please keep your claims timely for the future mass adjustment.
If you have any questions regarding this policy change, please contact HPE’s Customer Call Center at 1-800-766-4456.
The American Board of Family Medicine is sponsoring free support and tools to help GAFP members maximize and ease the transition to value-based care:
Georgia Academy of Family Physicians (GAFP) member practices can join the PRIME Registry for free for 3 years through the DAIQUERI Pilot.
The PRIME Registry turns your EHR data into actionable information
An additional benefit to those who participate in the PRIME registry through the DAIQUERI Pilot is the opportunity for Maintenance of Certification Part IV credit.
In order to sign up, simply go to the following link, fill out the information and sign the agreements to start.
Enrollment will end February 29 or at the first 50 physicians, whichever comes first.
If you would like additional information about the PRIME registry including the DAIQUERI Pilot
Contact John Johannides at firstname.lastname@example.org