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Medical Home Payment: It's Not Just About Coding Anymore


Medical Home Payment: It's Not Just About Coding Anymore C4K December Monthly Clinical Team Call/Webinar December 21, 2011 Joel Bradley, MD, FAAP – PowerPoint PPT presentation

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Title: Medical Home Payment: It's Not Just About Coding Anymore

Medical Home Payment It's Not Just About Coding
  • C4K December Monthly Clinical Team Call/Webinar
  • December 21, 2011
  • Joel Bradley, MD, FAAP

Contact Information
  • Email-
  • Phone- 615-493-9529

(No Transcript)
The Prevailing Winds
  • The U.S. health care delivery system continues to
    be fragmented- but now acknowledged.
  • Even when the individual health care services
    provided to a patient meet high standards of
    clinical quality, the coordination of care, which
    may be delivered by multiple providers in
    multiple settings, often is lacking.
  • Inadequate communication among providers, and
    between providers and patients and their
    families, is also common.
  • There is a vacuum of accountability for the total
    care of patients, the outcomes of their
    treatment, and the efficiency with which medical
    resources are used-but all vacuums get filled
  • There will be no new dollars for health care-
    likely overall cuts- new funding opportunities
    will be from cost savings by changing our systems
    of care

Filling Vacuums and Making Solutions-The PCMH
  • A complete patient centered medical home program
  • 1. a quality service delivery model
  • 2. A reimbursement model that recognizes the care

The Agenda-Creating Value in Your Practice
  • The Triple Aim- Improving quality of care, the
    cost of care, and the general health of the
  • Creating Value
  • Value Quality / Cost
  • 3. Payment will follow Value

Practice TransformationRequirements
  • The Medical Home Makeover is transformation - an
    evolution to an improved model of delivering
    health care, and creating value for patients ,
    payers, and your practice
  • Physician Leadership
  • Subject Matter Knowledge
  • Resources

Creating Value- What Families Want
  • A personal physician
  • A place other than the emergency room to receive
    care (access)
  • Convenience (access)
  • A Navigator (Care Coordination)
  • Lower costs of insurance and drugs

Creating Value- What Employers Want
  • A healthy workforce
  • Easy employee access to care
  • Controlled Cost of health insurance- stable

Creating Value- What Payers Want
  • A Network of Providers who can partner to-
  • Improve Quality- measured (HEDIS)
  • Lower Cost inpatient, emergency, and pharmacy
  • Use Evidenced Based Medicine
  • Create and maintain Access for their members
  • Receive and Use data to improve care

Accountable Care-Here We Go
A Key Concept-Accountable Care
  • An Accountable Care Organization (ACO) is defined
    as a group of physicians, other healthcare
    professionals, hospitals and other healthcare
    providers that accept a shared responsibility to
    deliver a broad set of medical services to a
    defined set of patients across the age spectrum
    and who are held accountable for the quality and
    cost of care provided through alignment of

Medical Home Program- Core Attributes with Value
  • Access- Improved Access to Care same day ,
    walk-in, afterhours, preventive care , proactive
    approach to a population of our patients within a
  • A New Care Model Office based Care
    Coordination/Management- The Chronic Disease
    Model, active patient Care Plans, Personnel and
    Processes for Patient Care Management and Care
  • Health Information Technology- (HIT)-Use of Data
    to Improve care- The providers act on patient
    care registries (data driven care opportunities)
  • Evidenced Based Medicine- Adoption and Adhenrence
    to proven diagnosis and treatment guidelines

National Payment Models Multimodal and
Evolving to Risk Model
  • Enhanced Fee for Service
  • Typically higher rates than non PCMH
  • Payment policy (afterhours care, care plan
  • Evolution to risk global payments /capitation
  • Prospective Payments- funding infrastructure
  • Care coordination
  • EHR
  • NCQA certification costs
  • Evolution to risk based on outcomes
  • Retrospective Payments- For Performance or Value
  • Utilization (cost)
  • Quality Indicators
  • Patient experience
  • Evolution to risk based on a Gain Share

Prospective- Care Coordination /Infrastructure
Improving the Fee Schedule for Key Medical Home
  • Non-Face-To-Face Services
  • Care Plan Oversight
  • Special Services Afterhours Care
  • Team Services

Care Plan Oversight- Why a Key Servicefor the
Medical Home?
  • Allows reimbursement for managing chronic
    illness and behavior
  • Pays for all non face to face time not billed
    with other nftf codes

Care Plan Oversight
  • Review of subsequent reports of patient status,
  • Review of related laboratory and other studies,
  • Communication (including telephone calls) for
    purposes of assessment or care decisions with
    health care professional(s), family member(s),
    surrogate decision maker(s) (eg, legal guardian)
    and/or key caregiver(s) involved in patient's

Care Plan Oversight
  • ?99339 Individual physician supervision of a
    patient (patient not present) in HOME,
    domiciliary or rest home (eg, assisted living
    facility) 15-29 minutes- Calendar Month
  • ?99340 30 minutes or more

The Key Servicesfor the Medical Home
  • Expanded Access After Hours Codes

After Hours Codes
  • 99050- when the office is normally closed
  • 99051 "during regularly scheduled evening,
    weekend, or holiday office hours, in addition to
    basic service.
  • Expect to see increase in payer recognition of
    this add-on service in support of Medical Home
  • Adds additional revenue for visits on weekends
    and evenings after 5pm

The Key Servicesfor the Medical Home
  • Team Care
  • Non-Physician Services

  • NURSE VISITS 99211 (19.71 for one visit)
    96150-96155 (21.07 per 15 min)
  • MEDICAL NUTRITION SERVICES 97802-97804 (31.94
    per 15 min)
  • PATIENT EDUCATION (new in 2006) 98960-1 (26.16
    per 30 min)
  • CMS 2011 Fee Schedule for Medicare

Prospective Payments
  • Payment provided in advance of the work
  • Typically directed for infrastructure support
  • Care Coordinators/ Care Managers
  • Implementation of EHR
  • PCMH Certification (e.g. NCQA)
  • Name varies- care coordination payment , clinical
    integration grant
  • Basis varies- per member per month or pmpm-
    range of 1.50 upward- for all patients or for
    those with special needs
  • May be a grant to begin your program and evolve
    over time to become performance based

The NEW Pay For Performance- PAY FOR VALUE
Review of P4P Programs- the Past
  • Typical- payment at the end of a measurement
    period (in addition to the fee schedule) for
    meeting targets for selected HEDIS quality or
    efficiency measures
  • ( By in large, most first generation P4P programs
    were not successful in making substantial gains
    in quality or in cost savings )

Review of P4P Programs- the Past
  • Examples- HEDIS Measure- Adolescent Well Visits
  • Threshold is 60 of all your teen patients need
    to have received by one year
  • Once threshold is met, a payment is triggered (no
    threshold, no payment) of 40 per patient who
    received the service

Review of P4P Programs- the Past
  • Examples- HEDIS Measure- Adolescent Well Visits-
    Target for payment is 60
  • Your practice has 100 teen patients
  • By December, 62 (62) had their preventive visit,
    for a payment of 62 x 40 2480.

Review of P4P Programs- Physician Perspective
  • What makes a good measure from your
  • Can you Impact?
  • Can you efficiently do the extra work needed to
    improve rates?
  • How much incentive is needed to sign onto a
  • Are there any incentives beside money?

Evolution of P4P Programs- Payment for Value
  • Payment at the end of a 12 month measurement
    period (in addition to the fee schedule) for
    meeting targets for quality- selected HEDIS
  • plus
  • Meeting threshold targets for Efficiency measures
    creates a cost savings pool (the gain) that can
    be shared

Evolution of P4P Programs- the Present and near
  • Example- 500 patients under one payer-
  • Quality Scores
  • 1. Adolescent well care- 100 of target
  • 2. Asthma care controller medication- 90
  • 3. ADHD Medication follow up- 65
  • Composite score 85

Evolution of P4P Programs- the Present and near
  • Example- 500 patients under one payer-
  • Your Efficiency Scores-
  • -10 reduction in ER visits over the past 6
    month reporting period and
  • - 20 reduction in admissions and
  • - 10 reduction in Pharmacy cost through
    generic conversions
  • Total savings 50,000

Evolution of P4P Programs- the Present and near
  • Your Gain Share payment for value is .
  • Quality score X Savings
  • 85 x 50,000 42,500
  • Your group divides up the money by its own rules,
    or if part of an ACO, by ACO rules

Payer Engagement-The First Meeting
  • Survey your practice- pick the top 4 or 5 payers
  • Create the Framework for the Value discussion
  • Request a meeting to present your PCMH
    transformation plan
  • Best payer contacts-
  • (door openers)- your provider service rep, the
    medical directors, and the directors of care and
    disease management

Resources- The First Meeting
  • Present Your PCMH Program and Implementation Plan
  • Request a partnership to improve care (4
  • Your request from the payer-
  • Data- utilization, quality, and patient risk
  • A Second Meeting
  • Then develop a population based plan for your

  • Develop the practice infrastructure which
    provides the best care for your patients AND take
    advantage of the payment opportunities ( PCMH )
  • Engage your payers- new payment opportunities
    should follow over time
  • You will have the option to play
  • The chances of both you and your patients
    winning will be good

ChangeIs Constant in Health Care
  • It is not necessary to change Survival is not
  • Edward Deming
  • Speaking to a group of Detroit automaker
    executives 1970s-

PCMH Resources
  • 1. AAP National Center for Medical Home
  • http//
  • Mentors, Toolkit
  • 2. Center for Medical Home Improvement
  • http//
  • Medical Home Index, Role of Family
  • 3. NCQA-
  • http//
  • Patient-Centered Medical Home (PCMH) 2011
    Recognition Program

PCMH Resources
  • 4.PCPCC- Patient Centered Medical Home
  • http//
  • Subject Matter- How and Why It works
  • Payment Rate Brief- 2010 a survey of pcmh
    reimbursement models
  • Outcomes Report- 2010- a summary of quality and
    cost improvement made by exiting PCMH programs
  • 5. Commonwealth Fund
  • http//
  • The national perspective on PCMH,ACO, and Health

AAP Coding Resources
  • AAP Coding Hotline ( is
    a resource for practitioners to submit coding
    questions and receive a response from AAP coding

AAP Core Coding Resources
  • AAP Pediatric Coding Newsletterproven coding
    solutions you cant afford to miss!
  • Month after month, AAP Pediatric Coding
    Newsletter helps you maximize payment, save
    time, and implement best business practices to
    support quality patient care. Included in this
    annual subscription product is print and online
    access to broad coverage of coding for pediatric
    primary care and subspecialty services.
  • Coding for Pediatrics 2012new 17th edition of
    the number 1 pediatric coding and billing
  • For beginners and advanced coders alike,
    this is the first place to look for
    pediatric-specific, AAP-endorsed, peer-reviewed
    coding solutionsall new and updated Current
    Procedural Terminology (CPT) and International
    Classification of Diseases, Ninth Revision,
    Clinical Modification (ICD-9-CM) pediatric
    codespractical recommendations, tips, and
    techniquesand much more.
  • 2012 Pediatric ICD-9-CM Coding Pocket
    Guideconvenient go-anywhere format!
  • Streamline pediatric diagnosis coding with
    this newly revised reference. Here are the basic
    guidelines for selecting appropriate codes for
    commonly encountered pediatric diagnoses and

Practice Management Online
  • Practice Management Online (PMO)
    (http// supports pediatricians
    in running a practice that is fiscally sound and
    efficient and provides quality health care to
    children and families.

  • Upcoming Webinars
  • ICD-10-CM Transition Its Not Just a MythIts
    Coming! (February 9, 2012)
  • Newborn and Neonatal Coding Issues (April 19,
  • Evaluation and Management Documentation
    Guidelines and Pitfalls of Electronic Medical
    Records (June 7, 2012)
  • Visit for additional
    information or to register!
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