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CMS Quality Payment Program

CMS Quality Payment Program


The Centers for Medicare & Medicaid Services (CMS) issued a notice of proposed rulemaking for implementing its Quality Payment Program (QPP) and with good reason. The expectation for eligible clinicians to begin performance reporting at the start of 2017, or face negative payment adjustments in 2019, is daunting, to say the least.

CMS actually intends to offer four ways to participate in the Quality Payment Program the first year.

Quality Payment Program


“In recognition of the wide diversity of physician practices, we intend for the Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017.


The Quality Payment Program offers two tracks for participation:

  • Merit-based Incentive Payment System (MIPS);
  • Advanced Alternate Payment Models (APMs).


Another options eligible clinicians may participate in either of these two tracks during the 2017 performance period to avoid a negative payment adjustment in 2019:

  • Submit “some” data to the QPP, including data from after Jan. 1, 2017.
  • Submit QPP information for a reduced number of days. This option would allow you to begin later than Jan. 1, 2017.
  • Submit QPP information for a full calendar year.
  1. Join an Advanced APM, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced APM in 2017, then you would not only avoid a negative payment adjustment, but qualify for a 5 percent incentive payment in 2019.

Hopefully, the QPP final rule, expected out Nov. 1, will explain these options in more detail.

How to report Medicare Teleconferences

How to report Medicare Teleconferences The Centers for Medicare & Medicaid Services (CMS) allows coverage for telehealth consultations, using dedicated G codes.

Medicare Teleconferences

Codes describing initial telehealth consultations apply to inpatients, including those in a skilled nursing facility (SNF), or to patients in an emergency department (ED):

  • G0425 Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth [problem focused history, problem focused examination, straightforward medical decision making]
  • G0426 Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth [detailed history, detailed examination, moderate complexity medical decision making]
  • G0427 Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth [comprehensive history, comprehensive examination, high complexity medical decision making]

Follow-up codes similarly apply to SNF or hospital inpatients, as well as to ED patients:

  • G0406 Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth [problem focused history, problem focused examination, straightforward medical decision making]
  • G0407 Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth [detailed history, detailed examination, moderate complexity medical decision making]
  • G0408 Follow-up inpatient consultation, complex, physicians typically spend 35 minutes communicating with the patient via telehealth [comprehensive history, comprehensive examination, high complexity medical decision making

Per the Medicare Claims Processing Manual, Chapter 12, section 190.3.1, subsequent hospital care services are limited to one telehealth visit every three days. Subsequent nursing facility care services are limited to one telehealth visit every 30 days.

Whether reporting initial or follow-up services, the provider must meet all three required elements (history, exam, MDM) to bill a particular level of service. For example, to report G0407, the provider must document at least a comprehensive history, a compressive exam, and high complexity MDM.

To demonstrate that the service matches the CMS definition of a consult, documentation should verify the following elements:

  • Arequest for opinion or advice, and a stated reason to substantiate the need for the service. Because the consulting provider bills the service, it’s in his or her best interest to document the request as part of the patient record. Specify that the visit is “consult” (not, for instance, a “referral,” which may signify to the payer a transfer of care rather than a request for consultation). If possible, ask the requesting provider to make the request in writing (e-mail, fax, a note sent with the patient, etc.), and make that part of the record, too.
  • Areport from the consulting provider, back to the requesting provider. The service is justified only if the consulting physician gives his opinion and/or advice to the requesting provider. Without a report back to the requesting provider, a consultation hasn’t occurred.
  • Telehealth services are available only to those patients in a qualified originating site. Telehealth originating sites must be located in a designated rural Health Professional Shortage Area (HPSA), located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract, or a county outside of a MSA. To determine a potential originating site’s eligibility for Medicare telehealth payment, visit the CMS website.
  • Medicare pays only for interactive video consultation services that mimic face-to-face interactions between patients and providers. CMS stipulates that video telecommunications system must permit “real-time communication between … the physician or practitioner at the distant site, and the beneficiary, at the originating site.”


When reporting an approved telehealth service, you must append modifier GT Via interactive audio and video telecommunications systems to the appropriate service code(s).

The modifier tells your Medicare contractor that the beneficiary was present at an eligible originating site when the telehealth service was furnished.


“For reporting non face-to-face” telehealth services, the

Are you ready for the ICD10 changes in 2017?

Are you ready for the ICD10 changes in 2017?

ICD10 Changes in 2017

• CMS will add 1,900 new ICD-10-CM codes, revise 422 codes, and delete 305 codes effective Oct. 1, 2016.
• Some revisions are as simple as a singular word change in the code, like from “of” to “due to.”
• There will be no longer the amnesty of the CMS grace period effective Oct. 1.
Major changes includes:
• Appendix with Z codes for long term use of drugs.
• Symbols/alerts with Z codes that can be used as primary Dx.
• MCC and CC Information — Major Complication & Comorbidity (MCC) and Complication & Comorbidity (CC) indicators and exclusions, and alerts for principal diagnosis as its own CC/MCC.
• Important 2017 code updates — 2,600 ICD-10-CM code changes, including 1,900 new and 422 revised codes.
• Color Illustrations — Colored full-page anatomical illustrations.
• Complete Official ICD-10-CM — View all 21 chapters, from infectious & parasitic diseases to injuries, including external causes and reasons for visit.
• Complete Official ICD-10-CM Coding Guidelines — Know the guidelines, which are key to using this elegant code set properly.
• Official alphabetic index and tabular list and index to external causes.
• Chapter Detailed Guidelines — Official guidelines specific to Tabular List chapters found before the chapters.
• Advanced Tables and Indexes — Official alphabetic index and tabular list and index to external causes. Table of drugs and chemicals and neoplasm table.
• Logical Color Coding — Color-coding and symbols for Medicare Code Edits (MCEs) for gender, primary diagnosis only, and age — newborn, pediatric, maternity, adult.

Status T Indicator Codes

Reporting Status T Indicator codes

The National Medicare Physician Fee Schedule contains Status T Indicator codes.  The reporting of these codes can be a bit challenging.  To begin with, here is a little background on the formation of the sets.

The Comprehensive Error Rate Testing program frequently identifies instances where CPT® and HCPCS Level II codes routinely bundled into related procedure codes are reported separately and paid. This is problematic because Medicare considers all services integral to accomplishing a procedure bundled into that procedure, and not separately payable. Use the

Fluids used to facilitate an injection or infusion of medications or other substances are incidental hydration and are not separately payable, nor are use of local anesthesia, IV start, access to indwelling IV, flush, and standard tubing, syringes, and other supplies. Code only for the drug and its administration.

All codes published in the Medicare Physician Fee Schedule (MPFS) are assigned a status indicator (SI). These indicators identify whether a code is active (A), restricted (R), bundled (T or P), etc.
Unlike status P (Bundled/Excluded) codes, which are not assigned relative value units (RVUs), status T codes do have RVUs; however, these codes are paid only if there are no other related SI A or R services payable under the MPFS, billed on the same date, by the same provider.
One way to determine if a code carries a status T indicator is to use the national Physician Fee Schedule Search tool. In the CMS site, under the Physician Fees Schedule Search tool select the appropriate year, select the Payment Policy Indicators option, and select the Single HCPCS Code option. Enter the code in question, such as 96523 Irrigation of implanted venous access device for drug delivery systems, and select All Modifiers. Finally, click Submit. The status indicator will be located in the second column, labeled Proc Stat.

Your Medicare administrative contractor also may be able to provide you with a list of its status T codes.
Refer to the Medicare Claims Processing Manual, Chapter 12, Section 20.3 for official bundling guidelines.

Documenting perinatal death

What is ICD-PM? Documenting perinatal death

Every year, worldwide, millions of babies die the first 28 days of life, and just as many are stillborn, reports the World Health Organization (WHO) in an Aug. 16 news release. Unfortunately, most stillborn babies and half of all newborn deaths are not recorded in a birth or death certificate. This lack of data prevents countries from taking effective and timely actions to prevent other babies from dying.  ICD-PM is intended to assist healthcare providers and those charged with death certification to correctly document underlying causes of death. This will improve the information available to coders, program managers, statistical offices and academics/researchers.

Documenting perinatal death


There are three distinct features of ICD-PM or Documenting perinatal death :

  • It captures the time of a perinatal death in relation to the antepartum (before the onset of labor), intrapartum (during labor, but before delivery) or neonatal period (up to day 7 of postnatal life).
  • It applies a multilayered approach to the classification of cause of death. In using ICD-PM, mutually exclusive clinical conditions that lead to the identification of a single cause of perinatal death may be determined and linked with an ICD code.
  • It links the contributing maternal condition, if any, with perinatal death.

WHO recently launched three publications to help countries improve their data on stillbirths and maternal and neonatal deaths using ICD-PM.

  • The first publication, the “WHO Application of the International Classification of Disease-10 to deaths during the perinatal period (ICD-PM),” is a standardized system for classifying stillbirths and neonatal deaths.The WHO application of ICD-10 to deaths during the perinatal period: ICD-PM This guide is intended to be used in conjunction with the three volumes of ICD-10. The suggested code should be verified, and possible additional information should be coded using the full ICD-10 volumes 1 and 3; rules for selection of underlying cause of death and certification of death apply in the way they are described in ICD-10 volume 2.
  • The second publication, “Making Every Baby Count: Audit and Review of Stillbirths and Neonatal Deaths,” is a guide to reviewing and investigating individual deaths for the purpose of recommending and implementing solutions to prevent similar ones in the future. It also incorporates ICD-PM classification to help providers complete at least a basic death review.Making Every Baby Count: Audit and Review of Stillbirths and Neonatal Deaths
  • The third publication, “Time to respond: a report on the global implementation of maternal death surveillance and response,” explains how to strengthen the maternal mortality review process in hospitals and clinics. The document also provides guidance for establishing a safe environment for health workers to improve quality of care within clinics and an approach to recording deaths occurring outside the health system, such as when mothers deliver at home.

WHO is also participating in a global multi-partner effort to improve the quality of health information, including data on maternal and child health, through the Health Data Collaborative. More than 30 global health organizations are contributing to the development of a user-friendly package of guidance and tools designed to strengthen countries’ health information systems.



ICD-10 CM strictly limits same day preventative visit and sick visit for same patient

ICD-10 CM strictly limits same day preventative visit and sick visit for same patient


ICD-10-CM strictly limits the circumstances under which a provider may report a same day preventative visit and sick visit for the same patient. Diagnosis code descriptions don’t allow split billing for sick patients at your office for a preventive exam. As per ICD-10-CM guidelines, the visit no longer qualifies as a preventive encounter, if the patient is symptomatic on arrival for a preventive visit. A sick visit may be billed, but the preventive visit should be rescheduled.


preventative visit and sick visit

Codes describing preventive encounters are found in categories Z00Encounter for general examination without complaint, suspected or reported diagnosis and Z01 Encounter for other special examination without complaint, suspected or reported diagnosis.

The codes necessarily include the category designation within their full descriptors:

Z00.0- Encounter for general examination without complaint, suspected or reported diagnosis; Encounter for general adult medical examination; Encounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologic examinations

Z00.1- Encounter for general examination without complaint, suspected or reported diagnosis; Encounter for newborn, infant and child health examinations

Z01.4- Encounter for other special examination without complaint, suspected or reported diagnosis; Encounter for gynecological examination

If the category descriptor does not apply, neither can the individual code in that category. By properly including the category designation into the descriptors, Z00.0-, Z00.1-, and Z01.4- are not appropriate if the patient has a current complaint, or a suspected or reported diagnosis. In other words, you cannot report a wellness encounter if the patient is sick.

Excludes Notes Strengthen the Rule


ICD-10-CM defines an Excludes1:

A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

The Excludes1 notation means you may not list the affected Z00/Z01 codes with signs or symptoms codes in field 21 of the claim form, even if you link the diagnoses to different line items in field 24 of the form. The payer may accept the claim, but that doesn’t mean it’s coded correctly. A payer is not allowed to override the Excludes1 edits; only the World Health Organization (WHO), which maintains the ICD-10 code set, has that authority

How to get paid for a school sports physical

How to get paid for a school or sports physical

Sometimes, schools may require a “sports physical” for students prior to participation in sports or other programs. Typically, a healthcare provider must perform a physical exam and fill out the required form.

sports physical

There are few choices to document and bill for these exams:

  • Some offices choose to set a flat fee to fill out the school physical form and collect it from the patient, without billing insurance. The patient agrees to pay the lower fee for the reduced exam required, and agrees not to file insurance.
  • The other common option is to incorporate the school physical into a well-child check. The form can be filed into the chart to document the exam, and the rest of the well-child check can be documented in the visit note; or, a full well-child check can be documented, with the form filled out, in addition. Because a full well-child check is performed, it can be billed to insurance.
  • Some offices have a strict policy and only offer one option, while others offer both and let the patient choose which works best for his or her situation. Either way, make sure the patient understands your policy and billing procedures.
  • Similar policies could be applied to other types of physicals, such as pre-employment physicals, commercial drivers license (CDL) physicals, etc. Note, however, that with the increasing regulations and certifications required (in some states) to perform a CDL physical, more providers are choosing to not offer a CDL physical as part of a wellness visit. The CDL physical requires an extensive exam, time, and decision-making, and does not allow enough time to address the preventive aspects of a wellness visit. Providers feel that performing a CDL physical as part of a wellness visit is a disservice to the patient because the provider is not able to adequately perform the comprehensive wellness visit, in addition to the CDL physical.
  • There is a CPT® code for filling out forms (99080), but it is not a covered benefit with most plans. Although you could report 99080 instead of billing the patient directly, the bill most likely will be the patient’s responsibility, after the insurance processes.
Clinical Documentation is the key to Audit-proof ICD-10 documentation

Good Clinical Documentation is the key to Audit-proof ICD-10 documentation

The two key principles that support diagnosis and procedure code selection are good clinical documentation and demonstrated medical necessity.  Clinical Documentation should accurately reflect the level of work for the care rendered, and support the selected diagnosis codes. Demonstrated medical necessity, CMS  defines medical necessity criterion for payment of services. Quality documentation must support the medical need for performed tests and assigned diagnoses. The volume of documentation does not correlate to medical necessity (i.e. more is not always better).

 Clinical Documentation


Basics of Clinical Documentation:

Over- or under-documentation results in either an incorrect diagnosis code selection or unreported ICD-10 diagnosis codes. All diagnosis codes  should reflect the care delivered, and every diagnosis code must have an appropriate treatment plan to be billable. Always select diagnosis codes to the highest known level of specificity at the time of the patient encounter.

Providers may fall short when documenting chronic conditions, especially now that they have more options to select from in ICD-10 (compared to ICD-9). When providers receive the right guidance, they are more likely to change this behavior and select codes that more clearly illustrate the clinical picture depicted in their documentation.

It is not necessary providers will be well versed in coding language, therefore important to communicate effectively using directives they can relate to.

Evidence-based practice guidelines are a major resource that providers can use to bolster documentation. Practice guidelines serve as the blueprint for care delivery and set medical protocol for a provider’s assessment and evaluation. When care follows these guidelines, documentation aligns with appropriate coding levels.

Practice guidelines have a valuable role in supporting documentation in each of the three key evaluation and management (E/M) components:

  • History
  • Physical Exam
  • Medical Decision Making
  • Better Documentation = Fewer Unspecified Codes
  • Peer and Coding Reviews Can Strengthen Providers’ Notes
  • Support and Strengthen Your Provider’s Documentation:
  • Documentation Should Reflect the Clinical Process

Points Providers Should Know About Clinical Documentation:

  1. Do not populate template-based electronic health records using copy and paste functions.
  2. Quantity of documentation does not equate to quality of documentation.
  3. Insufficient  documentation may force an unspecified code.
  4. Many ICD-10 diagnosis codes use clinical classifications for grouping.
  5. Evidence-based practice guidelines promote accurate documentation.
  6. Proper documentation will support proper diagnosis selection.
  7. Appropriate coding relies on accurate documentation.
  8. Medical necessity is supported by precise documentation.
  9. Sufficient documentation minimizes unspecified code selection.
  10. Concise documentation is substantiated in an audit.
Cardiac and hip fracture gets new bundled payment models

Cardiac and hip fracture gets new bundled payment models

The CMS has proposed new bundled payment models for high-quality cardiac and hip fracture care as part of continuing efforts to reward quality care at a lower cost.

The agency has also proposed an incentive payment program to encourage more use of cardiac rehabilitation.

The new models will create strong incentives for hospitals to work with physicians and other providers to reduce complications and hospital readmission rates and speed patient recovery, according to a notice of proposed rulemaking from the CMS.

The cardiac-care provisions include procedures related to caring for patients who require CABG or treatment for MI.

Cardiac and hip fracture

The new policies include:

  • New bundled payment models for cardiac care and the extension of the current Comprehensive Care for Joint Replacement model to include other hip and femur fracture surgeries besides hip replacements.
  • A new model that incentivizes physicians to increase the use of cardiac rehabilitation.
  • A new pathway that allows physicians who participate in bundled payment models to receive payment incentives under the Quality Payment Program, an implementation of the Medicare Access and CHIP Reauthorization Act.
  • The hospital which admits the patient for care for a MI, CABG or hip or femur fracture surgery will be responsible for the cost and quality of care provided to the Medicare patient for their hospital stay and 90 days after discharge. Hospitals will be paid a fixed price for all treatment. If a hospital delivers quality care at a price below the target, then it receives money back based on a per-patient formula at the end of the model performance year. When the cost of treatment exceeds the target, the hospital is required to reimburse Medicare.


Quality of care will be evaluated on:

  • Hospital readmission rates,
  • Emergency room visit rates,
  • Amount of care deferred beyond the 90-day post discharge period,
  • All-cause mortality rates,
  • Hospital Consumer Assessment of Healthcare Providers and Systems satisfaction surveys and beneficiary surveys.

According to the CMS, the proposed models will also help reach the administration’s goal of 50% of traditional Medicare payments flowing through alternative payment models by 2018.

Improving quality care and value are central to the ACC’s strategic plan.”

Billing for Smoking Cessation

Smoking Cessation Billing

Healthcare providers perform smoking cessation (tobacco use) counseling daily, but it is not necessary they may be documenting or reporting it appropriately. Guidance is needed to ensure all performed services are claimed and supported by complete documentation.

Smoking Cessation

The Centers for Medicare & Medicaid Services (CMS) set a standard for coverage which commercial payers might not follow.

CMS will cover tobacco cessation counseling for beneficiaries, per MLN Matters® article MM7133,

  • Who use tobacco (regardless of whether they have signs or symptoms of tobacco-related disease);
  • Who are competent and alert at the time counseling is provided; and
  • Who receive counseling furnished by a qualified physician or other Medicare-recognized practitioner.

Each payer may have its own restrictions for coverage, so inquire about a patient’s benefits prior to claim submission.

Documentation must include sufficient detail to support the claim, as with any time-based evaluation and management (E/M) service. Proper documentation for tobacco-use cessation counseling should include the total time spent face to face with the patient, and what was discussed. The patient’s desire or need to quit tobacco use, cessation techniques and resources, estimated quit date, and planned follow up should be noted within the patient’s medical record. Without this information, medical necessity for coverage may be questioned, which could result in denied or delayed payment.

Without documentation of significant and separately identifiable work, the payment for smoking cessation counseling may be included in the payment for the primary E/M service.

Private payers may follow CMS’ direction when it comes to billing requirements for these services; however, it’s important to know the patient’s insurance benefits.

Medicare will cover two cessation attempts per year. Each attempt may include a maximum of four intermediate or intensive counseling sessions.

The total annual benefit covers up to eight smoking and tobacco-use cessation counseling sessions in a 12-month period. The beneficiary may receive another eight counseling sessions during a second or subsequent year after 11 months have passed since the first Medicare covered cessation counseling session was performed.

It’s best to verify coverage criteria prior to claim submission.

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