Practice Notes

How to make the most of 4 Medicare reimbursement opportunities

by Naomi Levinthal, Krista Teske, and John Kontor, MD

As Medicare continues to drive down reimbursement rates and shift from volume to value, it’s critical for providers—whether participating in traditional FFS Medicare, Medicare ACOs, or Medicare Advantage—to take advantage of four key Medicare reimbursement opportunities.

There are three specific Medicare codes that providers can use to ready their organization for the shift from volume to value. These opportunities, while still rooted in the traditional fee-for-service payment mechanism, were explicitly designed by CMS to incentivize providers to gain the capabilities, competencies, and skills for success under value-based care. There are also numerous patient care benefits to each of these models as outlined below. The fourth opportunity regards a provider’s ability to code diagnoses in such a way that may maximize their overall reimbursement.

Here is a summary of the four opportunities.

Chronic Care Management (CCM) services

The newest code on this list incentivizes providers to manage Medicare patients’ chronic conditions remotely. To bill for this code, providers must furnish at least 20 minutes per month of non-face-to-face CCM services to Medicare patients with two or more chronic conditions. The national reimbursement rate for this code is just over $40 per Medicare beneficiary per month. Advanced practitioners can furnish CCM services without direct physician supervision.

Patient care benefits: Increased round-the-clock access to providers, enhanced care continuity across settings through the requirement of specific EMR use, stronger community of support services, ability to develop customized care plan with providers.

Potential revenue opportunity: $40 per Medicare beneficiary with 2+ chronic conditions per month; industry estimates between $90,000 and $237,000 per provider annually.

For more information:

Transitional Care Management codes

Transitional care management codes offer providers reimbursement for the non-face-to-face care furnished when patients transition from an acute care setting back to the community. The two care transition codes cover communication with the patient within two business days of discharge. Communication can occur by phone, email, or in-person.

Patient care benefits: Enhanced care continuity throughout transition home, expanded access to care providers throughout transition.

Potential revenue opportunity: According to the AAFP, $135-231 reimbursement every 30 days for qualifying patients .

The Annual Wellness Visit (AWV)

The AWV is a yearly preventive care visit offered at no cost to all Medicare Part B beneficiaries. The purpose of the visit is to identify patient risk factors and plan for future preventative service needs. The visit is well-reimbursed and can be conducted by any licensed health professional, or a team of professionals operating under the direct supervision of a physician. While the AWV is recognized as an important benefit, CMS reports that 85.5% of Medicare beneficiaries did not receive an AWV in 2014.

Patient care benefits: Annual opportunity to monitor health, ability to work with providers to develop preventative care plan, get connected to necessary community resources.

Potential revenue opportunity: According to CMS, $111-172 average annual reimbursement per qualifying patient.

For more information: Why the AWV is actually a big EHR opportunity

Hierarchical Condition Category (HCC)

HCC is a risk adjustment model developed by CMS in 2004. The model is used to adjust payments to health plans (under Medicare Advantage) and directly to providers (under MSSP, Pioneer, VBP, and NGACO) according to the health expenditure risk of their enrollees. The model measures disease burden and includes 70+ coding groups, which are cumulative, meaning a patient can have more than one HCC category assigned to them. Diagnoses determine the HCC Risk-Adjustment Factor (RAF), which directly impacts a health plan’s and/or provider’s payment the following year. Providers are paid more for higher RAF scores so it is in the provider’s best interest to effectively document patient encounters and capture all patient diagnoses in the EMR.

Patient care benefits: Helps to ensure providers have, document all necessary information on patient conditions, history; can ensure patients receive the appropriate level of care for their level of risk.

Potential revenue opportunity: Variable

For more information: Four ways to better track your patients' complexity—and get paid for it

Action items for providers

To effectively and compliantly capitalize on each of these Medicare reimbursement opportunities providers must increase patient visit volumes and enhance documentation compliance. To do so providers must:

1. Engage patients, providers, and staff. Provider organizations must educate clinicians and practice staff on these four types of reimbursement opportunities and develop marketing collateral to publicize these offerings to Medicare patients (where applicable).

2. Standardize patient identification and outreach. Provider organizations must develop standardized approaches to identify Medicare patients that may qualify for each of these types of services (i.e. clinical decision support to alert clinicians to eligible patients).

3. Optimize the care delivery model. Provider organizations should evaluate their care delivery model to develop a care approach that can easily fit into clinician and physician schedules. Providers should also see if there are any opportunities to better leverage advanced practitioners and/or Medical Assistants for care delivery.

4. Improve documentation efficiency. Develop EMR templates and workflows to effectively document patient conditions and furnished services, establish and educate clinicians on documentation protocols for each visit type, consider developing training sessions to enhance HCC risk score capture, validate documentation protocol adherence with internal audit processes.

Maximize your reimbursement opportunities

Clinovations, now part of the Advisory Board’s Consulting and Management Division, offers hands-on support to ambulatory practices looking to realize their full Medicare reimbursement potential. See how Clinovations can support your medical group.

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