Armando Javier Colón Aponte MSCJ, CBMA, COC, CASCC, CPPM,CFWAP, CWHBP, PCAP™’s Post

Read below for future changes related to claims and diagnostic codes—

Key facts about who loses and who wins in Medicare physician payment in Inquiry The day before I posted on the increased volume and intensity in Medicare payments to practitioners (not including drugs). But policy makers should know it may not be what they think, and grand ideas cause -arguably -distortions: 💲Inflation-adjusted reimbursement per beneficiary increased 9.9% over 05-21; this trend encapsulated a 64.8% increase in RVUs per beneficiary, offsetting a 33.6% inflation-adjusted conversion factor decline. 🧮RVU changes per bene across clinicians (+45.5% for physicians to +328.2% for non-physician practitioners) and by specialty (−36.1% for cardiac surgery to +1106% for nurse practitioners). ➡️Given RVU increases, conversion factor decreases, and inflation combined, reimbursement per beneficiary decreased 2.3% for physicians -varies positive for rheum, family practice treading water see figure 2; and increased 16.3% for limited-license physicians and 206.5% for non-physician practitioners. NOTE Understand the system: Under the MPFS, providers paid based on relative value units (RVUs), which define the relative value of a service, multiplied by a CMS set $ conversion factor (cf). When changes are large enough to trigger a budget neutrality adjustment, cuts are required elsewhere. Typically, cuts are achieved through the cf reduction that decreases payments for all services. For example, the cf declined significantly in 2009, 2011, and 2021 due to changes in patient cost sharing (aca and other), and increased reimbursements for evaluation and management services. A cut in cf is built into the baseline, dudes. Be careful what you ask for. Note there are other temporary year to year payments but this is about how the engine is working. #PFS #docpayment #NP #Rheumatology

> Medicare (CMS) proposes a payment model for physicians to interact with patients at the time and place of their choosing This proposal is revolutionary even though it is hidden in the (boring) physician fee schedule. It will move us towards patient centered care where patients can get virtual care and digital care as core parts of their care plan and healthcare workers will be reimbursed for doing this. Today's payment models are based on physician time spent with the patient. In some cases, there is a minimum 20-30 minute time limit before the physician can be paid. So answering my call, my email and my text may not be in the physician's financial interest. As a result, physicians are not incentivized to use technology to address patient needs because they get paid for the amount of time they spend with the patient. In a bold and surprising move, CMS is proposing introducing three new HCPCS codes to allow physicians to bill for helping patients: 1. GPCM1: Advanced primary care management services provided by clinical staff and directed by a physician. 2. GPCM2: Advanced primary care management services for a patient with multiple (two or more) chronic conditions 3. GPCM3: Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary with multiple (two or more) chronic conditions expected to last at least 12 months These are not based on the amount of time spent with the patient but based on providing certain services. In another surprise move, CMS is finally allowing nurse practitioners and physician assistants to order and bill these services. This welcome move will unburden physicians and enable other healthcare workers to play a bigger role in patient care. Finally CMS is also proposing reimbursement for some behavioral health treatments using FDA-approved devices. I believe this is the beginning of digital treatments becoming a core part of the care plans. I've said this before and I'll repeat it. I know our government and especially Medicare gets a lot of disdain. But I'm constantly impressed by how they are innovating to allow patients to get care in the manner they want, and at the time and place that is convenient to them. I'm looking forward to the future where patients and physicians can interact via frequent, short digital interactions than always going into the office for 30 minute appointments. And where virtual and digital care is an important part of a patient's care plan. You can read the details in the CMS 2025 Medicare Physician Fee Schedule Proposed Rule: https://lnkd.in/gNK4rBYN

The publication of the Medicare Physician Fee Schedule (MPFS) final rule on Nov. 1 leaves in place proposed physician fee cuts for 2025 and in fact bumps them slightly higher, to 2.93 percent, as a result of other changes in the fee schedule. “We are disappointed,” said Susan Dentzer, President and CEO of America’s Physician Groups. “Any action to blunt the crippling effect of the fee cuts will now be the responsibility of Congress.”   As widely reported, inflation-adjusted Medicare physician fees have fallen by 29 percent since 2001 due to fee schedule changes and the lack of a full update for medical practice inflation. APG looks forward to working with congressional policymakers in the coming weeks and months to shape plans for moderating the proposed fee cut, and ideally, eliminating it altogether.   Other aspects of the final MPFS rule are far more favorable for physician practices and APG member organizations, APG noted. “We welcome such measures as allowing eligible Accountable Care Organizations (ACOs) with a history of success in the Medicare Shared Savings Program, including many of our member groups, to receive advances on their earned shared savings,” Dentzer said. Also beneficial will be new coding and payment policies for advanced primary care management services that, as CMS noted, will constitute a new pathway to #accountablecare built into the fee schedule, and will help to increase the number of smaller physician practices committed to #valuebasedcare.

High-Level Findings and Common Causes of Improper Payments (Part 1 of a 3-Part Series)    The recently released “2024 Medicare Fee-for-Service Supplemental Improper Payment Data Report” offers critical insights into improper payment trends across Medicare programs. Since the report is so long, I am planning a three-part series to break down some of the key findings, explore root causes, and identify high-risk areas that demand attention from healthcare professionals, particularly those in mid-revenue cycle roles (coding, CDI, and leadership at all levels.    Key Findings at a Glance: The Medicare Fee-for-Service (FFS) program reported an improper payment rate of 7.66% for claims submitted between July 2022 and June 2023. While this translates to an impressive payment accuracy rate of more than 92%--not bad at all in our complex system, as coders are often held to a 95% accuracy expectation—the remaining gap amounts to billions of dollars in improper payments, highlighting opportunities for improvement.     Adjustments were made to the improper payment rate to reflect the rebilling of denied inpatient hospital claims under Medicare Part A as Medicare Part B claims.    Common Causes of Improper Payments: -Insufficient Documentation: Overwhelmingly, the lack of adequate documentation to support the billed service remains the most prevalent issue. Skilled nursing facilities, outpatient hospital services, and hospice care providers are among the biggest contributors to this category. But no one is immune. -Medical Necessity Errors: Claims often fail to provide documentation proving that the services rendered were medically necessary, particularly in complex procedures and inpatient admissions. -Incorrect Coding: Coding errors arise when documentation does not align with the submitted billing codes, frequently leading to claim denials or improper payments. -No Documentation: In some instances, providers fail to submit any supporting records for the billed service, leaving auditors unable to verify claims.    These findings underscore the importance of strengthening provider education, improving documentation standards, and investing in either technology or outside auditing to assist with coding accuracy. Healthcare professionals in mid-revenue cycle roles play a pivotal part in addressing these gaps, from claim reviews to compliance initiatives.     Have you read the report? Would love to hear your thoughts.    And stay tuned for our next post, where we’ll dive into improper payment rates for Evaluation and Management (E&M) services, which remain a particularly high-risk (and high rate) category for errors. https://lnkd.in/ejXP7Zs8

Local physicians are concerned about Medicare payment cuts impacting patient care. Dr. Terrence Cronin Jr., president of the American Academy of Dermatology, highlights the threat to care provision due to payment instability affecting medical practices' ability to cover expenses.   These cuts, approved by the Centers for Medicare & Medicaid Services, could lead to untreated illnesses and chronic conditions, risking patient health.   The American Medical Association and other medical organizations urge Congress to reverse these cuts, emphasizing the adverse effects on physician practices and patient access.   Physicians are closing practices or becoming hospital employees due to rising expenses and flat reimbursements. U.S. Rep. Bill Posey sponsors legislation to prevent future payment cuts, addressing concerns about maintaining seniors' access to care amid growing challenges for physicians.   Implementing care management services can boost practice revenue while enhancing overall patient care. By optimizing care coordination, monitoring patient outcomes, and improving healthcare delivery, practices can achieve better financial outcomes and patient satisfaction.    Our team of clinicians can provide expertise in developing and implementing care management programs, ensuring effective patient management and outcomes.   We are the One!   #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Florida Today

📌 CY2025 Medicare Physician Fee Schedule Final Rule 📌 On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a rule finalizing changes for Medicare payments under the PFS and other Medicare Part B policies, effective on or after January 1, 2025, see some of the highlights below. ⚠️ CY 2025 PFS conversion factor of $32.35, a decrease of $0.94 (or 2.83%) from the current CY 2024 conversion factor of $33.29. ⚠️ For CY 2025, we are finalizing our proposal to establish new coding and payment for caregiver training for direct care services and supports, policy to allow these CTS to be furnished via telehealth. ⚠️ CY 2025, we are finalizing our proposal to allow payment of the O/O E/M visit complexity add-on code, Healthcare Common Procedure Coding System (HCPCS) code G2211, when the O/O E/M base code — Current Procedural Terminology (CPT) codes 99202-99205, 99211-99215 — is reported by the same practitioner on the same day as an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventive service, including the Initial Preventive Physical Examination (IPPE), furnished in the office or outpatient setting. ⚠️ CMS is finalizing to continue the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations for CY 2025. ⚠️CY 2025, we will continue to permit distant site practitioners to use their currently enrolled practice locations instead of their home addresses when providing telehealth services from their home. ⚠️CMS is also finalizing a permanent adoption of a definition of direct supervision that allows the supervising physician or practitioner to provide such supervision via a virtual presence through real-time audio and visual interactive telecommunications for a certain subset of services that are required to be furnished under the direct supervision of a physician or other supervising practitioner. ⚠️For CY 2025, we are finalizing a policy to broaden the applicability of the transfer of care modifier 54, for all 90-day global surgical packages (global packages), in any case when a practitioner expects to furnish only the surgical procedure portion of the global package, including but not limited to when there is a formal, documented transfer of care as under current policy or an informal, non-documented but expected, transfer of care. ⚠️ For CY 2025, we are finalizing our proposal to establish coding and payment under the PFS for a new set of APCM services described by three new HCPCS G-codes (G0556, G0557, G0558). Click the link below to continue reading the other proposals for CY 2025. https://lnkd.in/ezy4y3zQ https://lnkd.in/emTP-kNS

Expect more focus on proceduralists with reports such as this one noting more declines. Doing more with less has become the rule and we know what this does. Remember how much organized effort was mounted against recent efforts to increase primary care payments - and it came from organized proceduralist groups. Budget neutrality, Regulatory Capture, and lobbying are tough to address with 1.4 trillion in spending a year against basic health access = especially with close position both to the feeding trough and to the design trough. Both positionings are essential for survival. "Inflation-adjusted reimbursement per beneficiary increased 9.9% over the 2005 to 2021 period; this trend encapsulated a 64.8% increase in RVUs per beneficiary, offsetting a 33.6% inflation-adjusted conversion factor decline. RVU changes per beneficiary varied widely across clinicians (+45.5% for physicians to +328.2% for non-physician practitioners) and by specialty (−36.1% for cardiac surgery to +1106% for nurse practitioners). Given RVU increases, conversion factor decreases, and inflation combined, reimbursement per beneficiary decreased 2.3% for physicians and increased 16.3% for limited-license physicians and 206.5% for non-physician practitioners. Overall, increased RVU volume per beneficiary has offset conversion factor declines within the budget neutral system. Substantial redistribution has occurred across provider types, with reimbursement declining slightly for physicians while tripling for non-physician practitioners. Certain specialties, particularly procedural specialties, have declined most.." https://lnkd.in/gi3U4CSq

Top 10 Things to Know About the CMS Proposed Rule addressing the Appeal Rights for Medicare Beneficiaries with "Observation Days" while in hospital. 1. Comment Period and Publication Date: The CMS proposed rule has a comment period ending on February 26, 2024, and was published in the Federal Register on December 27, 2023. 2. Purpose of the Rule: It establishes appeals processes for Medicare beneficiaries whose inpatient hospital stays were later reclassified to outpatient observation stays with outpatient services. 3. Prospective and Retrospective Appeals: The rule includes both prospective and retrospective appeals processes to ensure that the three-day Qualifying Hospital Stay (QHS) requirement for a patient's Medicare Part A skilled benefit is met. 4. Background of the Rule: The rule stems from a nationwide class action case, Alexander v. Azar, filed in 2011, which aimed to provide Medicare beneficiaries with the right to challenge their placement as outpatients receiving observation services. 5. Scope of Beneficiaries: Beneficiaries included in the class are those who had or will have Part A benefits denied for hospital inpatient services and Skilled Nursing Facility (SNF) care due to hospital reclassification, including those without Part B coverage at the time of hospitalization. 6. Expedited Appeals Process: An expedited appeals process is proposed for eligible beneficiaries who disagree with the hospital's decision to reclassify their status while still in the hospital. They can appeal to a Beneficiary & Family Centered Care - Quality Improvement Organization (BFCC-QIO) for a quick review. 7. Standard Appeals Process: For eligible beneficiaries not filing an expedited appeal, a standard appeals process is proposed. It allows them to challenge the hospital's decision after processing of the hospital’s Part B outpatient claim and any denial of SNF coverage. 8. Retrospective Appeals Process: A retrospective process is proposed for beneficiaries with hospital admissions on or after January 1, 2009, involving status changes before the implementation of prospective appeals processes. 9. Conforming Changes: Conforming changes are proposed to ensure the delivery of a related appeals notice as part of the Medicare provider agreement and modifications to QIO regulations for consistent review functions. 10. Legislative Support: Additionally, bipartisan bill H.R. 5138, the Improving Access to Medicare Coverage Act, supported by a coalition of 34 organizations, aims to count the time Medicare beneficiaries spend hospitalized in observation towards meeting the three-day prior inpatient stay requirement. Kris B. Harmony OTR/L, LNHA, MBA President and CEO KrisBHarmony, LLC [email protected] 617.595.6032

Overview The Centers for Medicare & Medicaid Services (CMS) has released the CY 2025 Physician Fee Schedule (PFS) final rule, which introduces updated payment structures and policies effective January 1, 2025. This rule focuses on enhancing equitable access to care, especially in behavioral health, and includes payment updates for safety planning, digital mental health devices, and intensive outpatient program services. While MANY other topics are in this article, such as: telehealth, E/M, dental and oral health, the below key takeaways focuses on BH. Key Takeaways - Medicare PFS Updates: Payments to physicians and providers will be adjusted based on the settings and resources involved, with different rates for office versus facility settings. - Behavioral Health Payment Expansion: New codes for safety planning interventions and follow-up services will enhance reimbursement for mental health crisis management. - Support for Digital Health: CMS will now provide payment for digital mental health treatment devices, aligning with behavioral health care plans. - New Codes for Mental Health Professionals: Additional HCPCS and G codes allow clinical psychologists, social workers, and other mental health professionals to bill for inter-professional consultations. - Feedback on IOP and CCBHCs: CMS received and is reviewing comments on Intensive Outpatient Program services and Certified Community Behavioral Health Clinics for future regulatory considerations. Conclusion This CMS rule is beneficial to medical billing and revenue management for healthcare practices, especially in behavioral health, as it broadens billing opportunities and streamlines coding. How Peak Medical Solutions Can Help Peak Medical Solutions can assist providers in navigating these new billing structures to maximize revenue and enhance compliance.