Tag: Medicare

Cognitive Assessment & Care Plan Services

If your patient shows signs of cognitive impairment during a routine visit, Medicare covers a separate visit to more thoroughly assess your patient’s cognitive function and develop a care plan – use CPT code 99483 to bill for this service. 

Effective January 1, 2021, Medicare increased payment for these services to $282 (may be geographically adjusted) when provided in an office setting, added these services to the definition of primary care services in the Medicare Shared Savings Program, and permanently covered these services via telehealth. Use CPT code 99483 to bill for both in-person and telehealth services.

How Do I Get Started?

Detecting cognitive impairment is a required element of Medicare’s Annual Wellness Visit (AWV). You can also detect cognitive impairment as part of a routine visit through direct observation or by considering information from the patient, family, friends, caregivers, and others. You may also use a brief cognitive test and evaluate health disparities, chronic conditions, and other factors that contribute to increased risk of cognitive impairment.

If you detect cognitive impairment at an AWV or other routine visit, you may perform a more detailed cognitive assessment and develop a care plan during a separate visit. This additional evaluation may be helpful to diagnose a person with dementia, such as Alzheimer’s disease, and to identify treatable causes or co-occurring conditions such as depression or anxiety. 

Who Can Offer a Cognitive Assessment?  

Any clinician eligible to report evaluation and management (E/M) services can offer this service. Eligible providers include: 

  • Physicians (MD and DO)
  • Nurse practitioners
  • Clinical nurse specialists
  • Physician assistants

Where Can I Perform the Cognitive Assessment?   

You can perform the assessment at any of these locations:

  • Office or outpatient setting
  • Private residence
  • Care facility
  • Rest home
  • Via telehealth

What’s Included in a Cognitive Assessment? 

The cognitive assessment includes a detailed history and patient exam. There must be an independent historian for assessments and corresponding care plans provided under CPT code 99483. An independent historian can be a parent, spouse, guardian, or another individual who provides patient history when a patient isn’t able to provide complete or reliable medical history. 

Typically, you would spend 50 minutes face-to-face with the patient and independent historian to perform the following elements during the cognitive assessment: 

  • Examine the patient with a focus on observing cognition 
  • Record and review the patient’s history, reports, and records 
  • Conduct a functional assessment of Basic and Instrumental Activities of Daily Living, including decision-making capacity
  • Use standardized instruments for staging of dementia like the Functional Assessment Staging Test (FAST) and Clinical Dementia Rating (CDR)
  • Reconcile and review for high-risk medications, if applicable 
  • Use standardized screening instruments to evaluate for neuropsychiatric and behavioral symptoms, including depression and anxiety
  • Conduct a safety evaluation for home and motor vehicle operation 
  • Identify social supports including how much caregivers know and are willing to provide care
  • Address Advance Care Planning and any palliative care needs 

NOTES

Notes

Data reflect NCQA’s 2019 ratings of Medicaid managed care plans. The plans included in the NCQA data do not always match the MCOs in other tables in the Medicaid Managed Care Market Tracker, or they may appear under different names. Discrepancies may be due to differences across reports and sources, timeframes, and other factors. MCOs not accredited or rated by NCQA may be accredited or rated by other organizations.

The NCQA plan overall rating scale is 0-5 (0 is lower performance, 5 is higher performance). NCQA accreditation is as of June 30, 2018. For more information about how NCQA rates plans, please see NCQA’s methodology.

Sources

NCQA Health Insurance Plan Ratings 2018-2019 – Summary Report (Medicaid). Special Data Request, October 2019.

Definitions

Partial Data Reported: Plans with partial data do not receive a rating, but NCQA lists them in the ratings and shows their scores on the measures they report. A plan is considered to have partial data if it submits HEDIS and CAHPS measure data for public reporting, but has insufficient data for one or more measures, submits HEDIS data for public reporting but does not submit CAHPS data, or vice versa, or earned NCQA Accreditation without HEDIS data (health plan accreditation standards only) and did not submit HEDIS or CAHPS data for public reporting.

No Data Reported: Plans that submit results but do not report data publicly, or plans that report no HEDIS, CAHPS or accreditation information to NCQA, are given a rating status of “No Data Reported”.

Insufficient Data: Plan has “missing values” (i.e., NA or NB) in more than 50 percent of the weight of the measures used in the methodology.

CMS Bundled Payments for Care Improvement (BPCI) Initiative: A Discussion on Bundled Payments

There is a large disconnect between what occurs after a patient is discharged from a hospital (acute) and what occurs thereafter. The quality of care is entirely unmanaged, uncontrolled, and unmonitored. Moreover, the patient is placed at greater risk whe

Understanding the CMS Bundled Payments for Care Improvement (BPCI) Initiative

In recent years, healthcare has been undergoing a significant transformation, driven by the need to improve care delivery and reduce costs. One of the key initiatives in this transformation is the Bundled Payments for Care Improvement (BPCI) program, introduced by the Centers for Medicare & Medicaid Services (CMS). The BPCI program is part of a broader effort to move the U.S. healthcare system towards value-based care, focusing on quality outcomes rather than the volume of services.

What is the BPCI Initiative?

The BPCI initiative was launched as part of the Affordable Care Act (ACA), which allowed the establishment of the Center for Medicare and Medicaid Innovation. The goal of this center is to pilot and expand innovative payment models that improve healthcare quality while reducing costs. BPCI is one of the many alternative payment models (APMs) being tested to align financial incentives with the quality of care provided, particularly in the post-acute care (PAC) setting.

The BPCI program focuses on bundled payments, which means that instead of paying for each service separately, healthcare providers receive a single, comprehensive payment for an entire episode of care. This “bundle” covers all services related to a patient’s treatment, including post-hospitalization care, for a specified period (e.g., 30 or 90 days). The goal is to incentivize providers to deliver coordinated, high-quality care that reduces unnecessary services and prevents avoidable readmissions.

Why Focus on Post-Acute Care?

One of the most challenging areas of healthcare to manage, particularly within the Medicare Fee-For-Service (FFS) program, is post-acute care. After patients are discharged from the hospital, they often require further care in settings such as inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home health agencies (HHAs). The costs and quality of care in these settings vary significantly across the country, contributing to wide regional disparities in Medicare spending. In fact, 73% of the variation in Medicare spending is attributed to differences in post-acute care settings.

The BPCI initiative specifically targets these post-acute care settings because of the high cost and the potential for improvement. For example, about 20% of Medicare patients are readmitted to the hospital within 30 days of discharge, and research suggests that 75% of these readmissions could be prevented with better care coordination.

The BPCI Models

The BPCI initiative includes four different models, each offering a different approach to bundled payments:

  1. Model 1: Retrospective Acute Care Hospital Stay Only – This model focuses on hospital costs for acute care stays.
  2. Model 2: Retrospective Acute and Post-Acute Care Episode – In this model, hospitals are financially responsible for both the acute care and all post-acute care services provided within 30 or 90 days of discharge.
  3. Model 3: Retrospective Post-Acute Care Only – This model places post-acute care providers (e.g., SNFs, HHAs) at financial risk for the services they provide after a hospital discharge.
  4. Model 4: Prospective Acute Care Hospital Stay Only – In this model, hospitals receive a single, upfront payment for an acute care stay, and they cannot bill for any additional services, even if the patient is readmitted within 30 days.

Model 2 is the most complex and widely adopted model, as it requires hospitals to manage the entire episode of care, including both acute and post-acute services. The financial risk is reconciled retrospectively, meaning that CMS reviews the total cost of care after the episode is complete and compares it to a pre-determined target price. If the costs are lower than the target, the hospital may share in the savings; if the costs are higher, the hospital is responsible for the excess.

Implementation Strategies for Success

To succeed in the BPCI initiative, hospitals and post-acute care providers need to collaborate closely. Many hospitals are implementing strategies such as narrowing their networks to include only high-performing post-acute care providers. This ensures that patients are discharged to facilities with strong track records in quality care and low readmission rates.

Hospitals are also using tools like patient choice letters, which list all available post-acute care providers but highlight those that have been vetted for quality. This approach, known as “soft steerage,” helps guide patients toward the best providers without restricting their choices.

In addition to collaboration, data sharing and technology play a crucial role in the success of BPCI. Hospitals need visibility into the patient’s care journey after discharge, which can be facilitated through electronic health records and other data integration tools. This allows for better coordination and monitoring of patient outcomes across the continuum of care.

Challenges and Opportunities

While the BPCI initiative offers significant opportunities for improving care and reducing costs, it also presents challenges. One major issue is the complexity of managing bundled payments, especially with the retrospective reconciliation process that introduces delays in financial feedback. Hospitals need to track performance in real-time and adjust their strategies based on ongoing data, rather than waiting for quarterly reconciliations from CMS.

Another challenge is managing high-risk patients and outlier cases, which can significantly skew financial outcomes. However, as bundled payment models continue to evolve and expand, hospitals that proactively adapt to these challenges will be better positioned for success in the shifting healthcare landscape.

Conclusion

The BPCI initiative is an important step towards a value-based healthcare system, particularly in managing the costly and often fragmented post-acute care segment. By aligning financial incentives with quality outcomes, the BPCI program encourages providers to deliver more coordinated, efficient care, reducing unnecessary services and preventable readmissions.

As bundled payment models continue to expand, healthcare providers who embrace this shift now will be better prepared for the future. By focusing on collaboration, data integration, and patient-centered care, hospitals can succeed in the BPCI initiative and contribute to a more sustainable healthcare system.

2021 Performance Period Eligible Professional / Eligible Clinician eCQMs

The document outlines 47 electronic clinical quality measures (eCQMs) for Eligible Professionals/Clinicians for the 2021 performance period. It categorizes various measures based on quality domains, including effective clinical care, community health, and patient safety, while indicating eligibility for telehealth in select measures.

2021 Performance Period Eligible Professional / Eligible Clinician eCQMs
Total number of EP/EC eCQMs: 47

Measure NameCMS eCQM IDQuality DomainNQF IDMIPS Quality IDMeaningful Measure AreaTelehealth Eligible*
Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentCMS161v9Effective Clinical Care0104e107Prevention, Treatment, and Management of Mental HealthYes
Anti-depressant Medication ManagementCMS128v9Effective Clinical CareNot Applicable009Prevention, Treatment, and Management of Mental HealthYes
Appropriate Testing for PharyngitisCMS146v9Efficiency and Cost ReductionNot Applicable066Appropriate Use of HealthcareYes
Appropriate Treatment for Upper Respiratory Infection (URI)CMS154v9Efficiency and Cost ReductionNot Applicable065Appropriate Use of HealthcareYes
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic FractureCMS249v3Efficiency and Cost Reduction3475e472Appropriate Use of HealthcareYes
Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapyCMS645v4Effective Clinical CareNot Applicable462Management of Chronic ConditionsYes
Breast Cancer ScreeningCMS125v9Effective Clinical CareNot Applicable112Preventive CareYes
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract SurgeryCMS133v9Effective Clinical Care0565e191Management of Chronic ConditionsNo
Cervical Cancer ScreeningCMS124v9Effective Clinical CareNot Applicable309Preventive CareYes
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentCMS177v9Patient Safety1365e382Prevention, Treatment, and Management of Mental HealthYes
Childhood Immunization StatusCMS117v9Community/Population HealthNot Applicable240Preventive CareYes
Children Who Have Dental Decay or CavitiesCMS75v9Community/Population HealthNot Applicable378Preventive CareNo
Chlamydia Screening for WomenCMS153v9Community/Population HealthNot Applicable310Preventive CareYes
Closing the Referral Loop: Receipt of Specialist ReportCMS50v9Communication and Care CoordinationNot Applicable374Transfer of Health Information and InteroperabilityYes
Colorectal Cancer ScreeningCMS130v9Effective Clinical CareNot Applicable113Preventive CareYes
Controlling High Blood PressureCMS165v9Effective Clinical CareNot Applicable236Management of Chronic ConditionsYes
Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)CMS145v9Effective Clinical Care0070e007Management of Chronic ConditionsYes
Dementia: Cognitive AssessmentCMS149v9Effective Clinical Care2872e281Prevention, Treatment, and Management of Mental HealthYes
Depression Remission at Twelve MonthsCMS159v9Effective Clinical Care0710e370Prevention, Treatment, and Management of Mental HealthYes
Diabetes: Eye ExamCMS131v9Effective Clinical CareNot Applicable117Management of Chronic ConditionsYes
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)CMS122v9Effective Clinical CareNot Applicable001Management of Chronic ConditionsYes
Diabetes: Medical Attention for NephropathyCMS134v9Effective Clinical CareNot Applicable119Management of Chronic ConditionsYes
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes CareCMS142v9Communication and Care CoordinationNot Applicable019Transfer of Health Information and InteroperabilityNo
Documentation of Current Medications in the Medical RecordCMS68v10Patient Safety0419e130Medication ManagementYes
Falls: Screening for Future Fall RiskCMS139v9Patient SafetyNot Applicable318Preventable Healthcare HarmYes
Follow-Up Care for Children Prescribed ADHD Medication (ADD)CMS136v10Effective Clinical CareNot Applicable366Prevention, Treatment, and Management of Mental HealthYes
Functional Status Assessment for Total Hip ReplacementCMS56v9Person and Caregiver-Centered Experience and OutcomesNot Applicable376Functional OutcomesYes
Functional Status Assessment for Total Knee ReplacementCMS66v9Person and Caregiver-Centered Experience and OutcomesNot Applicable375Functional OutcomesYes
Functional Status Assessments for Congestive Heart FailureCMS90v10Person and Caregiver-Centered Experience and OutcomesNot Applicable377Functional OutcomesYes
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)CMS135v9Effective Clinical Care0081e005Management of Chronic ConditionsYes
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)CMS144v9Effective Clinical Care0083e008Management of Chronic ConditionsYes
HIV ScreeningCMS349v3Community/Population HealthNot Applicable475Preventive CareYes
Initiation and Engagement of Alcohol and Other Drug Dependence TreatmentCMS137v9Effective Clinical CareNot Applicable305Prevention and Treatment of Opioid and Substance Use DisordersYes
Oncology: Medical and Radiation – Pain Intensity QuantifiedCMS157v9Person and Caregiver-Centered Experience and Outcomes0384e143Management of Chronic ConditionsYes
Pneumococcal Vaccination Status for Older AdultsCMS127v9Community/Population HealthNot Applicable111Preventive CareYes
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanCMS69v9Community/Population HealthNot Applicable128Preventive CareNo
Preventive Care and Screening: Influenza ImmunizationCMS147v10Community/Population Health0041e110Preventive CareYes
Preventive Care and Screening: Screening for Depression and Follow-Up PlanCMS2v10Community/Population Health0418e134Prevention, Treatment, and Management of Mental HealthYes
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedCMS22v9Community/Population HealthNot Applicable317Preventive CareNo
Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionCMS138v9Community/Population Health0028e226Prevention and Treatment of Opioid and Substance Use DisordersYes
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including DentistsCMS74v10Effective Clinical CareNot Applicable379Preventive CareYes
Primary Open-Angle Glaucoma (POAG): Optic Nerve EvaluationCMS143v9Effective Clinical Care0086e012Management of Chronic ConditionsNo
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer PatientsCMS129v10Efficiency and Cost Reduction0389e102Appropriate Use of HealthcareNo
Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseCMS347v4Effective Clinical CareNot Applicable438Management of Chronic ConditionsYes
Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic HyperplasiaCMS771v2Person and Caregiver-Centered Experience and OutcomesNot Applicable476Functional OutcomesNo
Use of High-Risk Medications in Older AdultsCMS156v9Patient SafetyNot Applicable238Medication ManagementYes
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and AdolescentsCMS155v9Community/Population HealthNot Applicable239Preventive CareYes

Statutory and Plan-Bid Components of the Regional MA Benchmarks

Carriers set their actual prices by bidding against the capitation payment amounts. Carriers with plans that do well on Medicare Advantage program quality measures get a higher monthly capitation payment.

Statutory and Plan-Bid Components of the Regional MA Benchmarks

The annual election period for 2020 coverage is set to start Oct. 15 and run until Dec. 7. The capitation payment spreadsheet below shows about how much Medicare Advantage program managers think they should be paying each month for each Medicare Advantage plan enrollee’s care.

Carriers set their actual prices by bidding against the capitation payment amounts. Carriers with plans that do well on Medicare Advantage program quality measures get a higher monthly capitation payment.

  • The 2020 county-level averages range from $755 per month, in Presidio, Texas, up to $1,609, in Nome, Alaska.
  • To simplify things, we calculated state-level averages. The 2020 state-level averages ranged from $883 per month, in Hawaii, up to $1,168, in Alaska.
  • We also calculated how fast each state’s average capitation level changed between 2019 and 2020. The year-over-year change ranged from 4%, in Delaware, up to 8.2%, in one state.

ACCESS THE 2021 MEDICARE RATEBOOK: 2021 Medicare Ratebook (National, County Level Capitation Rates)

Determining Medicare payment for regional MA plans

Aside from a few special payment incentives, payment for regional MA plans is determined like payment for local plans, except that the benchmarks are calculated differently. CMS determines the benchmarks for the MA regional plans by using a more complicated formula that incorporates the plan bids. A region’s benchmark is a weighted average of the average county rate and the average plan bid.

As directed by law, CMS computes the average county rate as the individual county rates weighted by the number of Medicare beneficiaries who live in each county. The average plan bid is each plan’s bid weighted by each plan’s projected number of enrollees. CMS then combines the average county rate and the average bid into an overall average. In calculating the overall average, the average bid is weighted by the number of enrollees in all private plans across the country, and the average county rate is weighted by the number of all Medicare beneficiaries who remain in FFS Medicare.

#CMS #FFS Medicare #Medicare #2021RateBook

Title 42. Public HealthChapter IV. CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES Subchapter B. MEDICARE PROGRAM Part 422. MEDICARE ADVANTAGE PROGRAM Subpart F. Submission of Bids, Premiums, and Related Information and Plan Approval Section 422.258. Calculation of benchmarks.

Physical Therapy Incident-to Billing Guidance

Evaluation and Management Coding for Physical Medicine and Rehabilitation

Incident-to services are services performed that are integral to and an incidental component of the physician’s professional services in an outpatient setting. Such services can be services performed, where permitted by the physician’s licensure rules, by auxiliary personnel, which may Include the physician’s staff.

For example, a chiropractic assistant applying electrical stimulation pursuant to the physician’s order and under that doctor’s direct (on-premise) supervision. While incident-to services are commonly performed by mid-level providers known as NPPs such as physician assistants (PAs), advanced registered nurse practitioners (ARNPs), and certified nurse midwives, for Medicare purposes, “auxiliary personnel can be anyone from an assistant to another physician provided that the ordering/supervising physician’s license permits delegation of the service that is performed by auxiliary staff.”

“auxiliary personnel can be anyone from an assistant to another physician provided that the ordering/supervising physician’s license permits delegation of the service that is performed by auxiliary staff.”


To bill services incident to, the physician must have initiated the care by personally performing the examination and personally developing the diagnosis and the plan of care. Auxiliary staff may perform services ordered where such delegation is permitted under the doctor’s license, provided that the physician is in the office suite providing supervision.

The physician does not need to be in the room, but they must be in the office and immediately available to intervene if needed. For physical and occupational therapists, the rule Is slightly different. Where permitted by their licensure rules, certified assistants can provide direct patient care under the supervision of a licensed PT/OT pursuant to a plan of care developed by the physical or occupational therapist and approved by a
medical physician.