Discover Sample Attorney Billing Descriptions for Planning

Sample attorney billing descriptions for Planning

and with no further Ado I would like to welcome Tori Fields Tori here's a lay for you we obviously can't get you one in person uh we're sharing with you a beautiful lay also as a sign of our thanks for coming and talking with us today Tory Fields is a mph like me yay go public health she's a consultant for health plans purchasers and academic and academic centers evaluating the impact of care models and clinical workflows on achieving The Institute for healthc care improvements Triple A she currently serves as a strategic advisor to the center to Advan paliative care known as capsi the coalition to transform Advanced Care which is CAC Center for Health care strategies better care Playbook and the National Academy for State Health policy seek her work includes analysis and development of state and federal policies that improve access to highquality care for people with serious illness and their caregivers she works with State Medicaid agencies across the country to develop and evaluate care models and benefits and with federal agencies to incorporate best practices into care model design and implementation very importantly for us her work includes the design and implementation of communitybased care benefits here in Hawaii as well as in California and she is working on Workforce Development projects to improve the lives of people with serious illness and their caregivers in Oregon New Jersey and New York so Tori thank you very much for coming today we're really pleased to have you and take it away oh thank you so much uh Aloha everybody and thank you for introducing yourselves already I am going to share my screen so as spent a lot of time thinking about how to optimize billing and coding um un uh very much like Janette I don't like fundraising I like things being sustainable uh which means that sometimes you know you have to actually bill for your services and um these rules for Advanced Care planning change all the time so there is a group of folks who are uh somewhat crazy like me um and they are part of the coalition to transform care and we track The Physician fee schedule to make sure that we have the most upto-date information on how advanced care planning is being uh build for today and what are some of the rules around needing uh that you need to know in order to do that effectively um one of the really interesting things that happened recently was the release of the uh Office of the Inspector General oig report on Advanced Care planning billing codes and what they found was that a fair number of Advanced Care planning billing codes and uh billing efforts actually did not follow the rules the punchline so why uh after all this investigation what they found was that the rules were just not very clear about what you need to do in order for Advanced Care planning to count and uh this presentation is an effort to help give you some tools to know exactly what you need to do to document and to code for Advanced Care planning um at the end there is going to be some FAQs Etc and I am going to spare you from reading everything on every slide but you will get these slides afterward as well and we'll have those FAQs as part of this presentation learning objectives i' I'd like to provide some awareness about the opportunities that clinicians uh have for reimbursement for Advanced Care planning this is not just for Physicians this is also for your lcsws for your social workers uh who are also able to build for Advanced Care planning in certain circumstances I'd like to share some uh information about how to bill and document for qualified Advanced Care planning visits and then we are going to um end with some highlevel information about this new benefit that Janette has been um you know tantalizing you about with this P of care benefit where Advanced Care planning is included but it's a bigger pallative care package um I am not a billing in expert so just want to give you a disclaimer there um I'm quite good at optimizing revenue for practices and in making sure that uh billing and coding is accurate but uh make sure you also consult with a certified coding consultant that's me Janette already introduced me so let's get to it the first thing to really understand is that there certain group of codes that really are optimized around time what we know is that counseling and care coordination and Advanced Care planning take a variable amount of time depending on the complexity of the patient so these are codes that are time based it's the first thing to remember so you're going to want to get really good at documenting the start and stop time of your conversations with your patients despite being distinct activities care coordination and Advanced Care planning can occur at different times during the same encounter or as a patient's needs dictate so you can actually bill for both of these things when more than 50% of the practitioner or patient and or the family en counter time is spent counseling and or in coordinating care time becomes the controlling factor to qualify for a particular level of evaluation and management for both counseling and care coordination it is important to clearly describe the details of the activity that you're discussing counseling sessions should clearly document who participated where where and when it occurred and likewise what topics were discussed what decisions were made and how these decisions will be implmented should all of those things be documented remember that when these activities occur in an outpatient setting the documentation must include a statement that affirms that the patient was present and they were face Toof face with a practitioner documenting care coordination activities must be equally specific to ensure that the other members of your interdisciplinary team are able to integrate any changes in the care plan and work on behalf of the patient this is one area that illustrates the critical importance of adhering to the basic fundamentals of documentation so I'm just going to interrupt you Tori I'm looking at counseling and care coordination as a slide yep okay that's fine is that where we are that's where we are sorry I just had a couple other people ask me that question too so good carry on sorry to interrupt you much of the success of the activities that we'll be talking about um is dependent on your to document the event clearly and competently so these are the things that you're if you're having an advanced care planning or a counseling conversation these are the things that you are going to want to document so diagnostic results that you discussed these things that you discussed prognosis risks and benefits of treatment options instructions for treatment or followup importance of compliance with treatment options and how you would reduce risk factors so this is a conversation it's not just documentation these notes also need to be legible and accurate and relevant and you need to sign them I hate to say that but you need to sign them that's going to be really important a lot of the things that we found uh is that we there were a lot of document there was a lot of documentation about these conversations but they didn't really go anywhere and they were not legible or signed so let's get into Advanced Care planning Advanced Care planning when done by physicians and other qualified professionals such as nurse practitioners and clinical social workers often occurs at multiple times throughout a person's course of treatment and through out their Pala of care journey and they can occur many times in concert or in relation to somebody else's other planned activities like a standard office visit it's important for practitioners to avoid co-mingling Advanced Care planning with evaluation and Management Services because both of these things are specialized Services required a skilled professional and each activity should be valued separately in order for you to get credit and to illustrate the detailed level of specialized services that a person actually received be aware that when the patient and family indicate that they want to discuss Advanced Care planning and goals of care within an evaluation and management visit this can then trigger your ability to be reimbursed for an advanced care planning um documentation make sure as I shared earlier that you note the time and that you segregate the Advanced Care planning discussion appropriately so that you can build out the time for the evaluation and management and the Advanced Care planning separately that's where there's some uh tricky math that can occur sometimes in doing so uh the documented information you capture will need to be specific accurate and complete and you will be able to be credited for both an enm code and Advanced Care planning provided that you're able um to document these things clearly so these are the six bullets that you need need in order for your Advan care planning documentation to count so document the Advanced Care planning time and services separately from your office visit or your enm code use a start and end time to accurately capture billable time document who was present in addition to the patient so did they have a caregiver did they have multiple caregivers who is actually present for this conversation and then document the specifics of the discussion what was discussed facilitate interdisciplinary team Communications meaning share that Advanced Care planning chart note and when you are discussing these goals for care you're actually able to be build separately for the office visit and Advanced Care planning your team is going to thank you if you're able to count for both before we take a look at encounter-based billing I thought it would be best to provide um you with a list to help it help you clarify when somebody should actually bill for their time so as you review the list of billable activities you'll find that many of them occur in conjunction with other activities please be sure to be accurate in the time that you're recording and make sure to clearly document the nature of the activity so all of these things can actually be counted um as time-based billing for example in preparation for somebody's visit uh you may have reviewed results from somebody's latest CT scan confirming that a b bone metastasis has expanded to include the left hip and the sacral spine another reminder is that uh teaching which is generally not part of discussion or topic leading to a discussion is not billable so in order to really document for Advanced Care planning you're documenting only for the conversation that you're having with that person in a hospital or a facility there are uh time-based billing codes so this is really an intention to give you some clear information information and Direction about the times when time based billing can be used and Advanced Care planning is really one of those times so you can use Advanced Care planning the billing code for Advanced Care planning when more than 50% of the face-to-face encounter with the patient Andor family was spent on counseling Andor care coordination you can do that in the hospital Andor the nursing facil faity and you need to ensure one that you're documenting the total length of time and where that encounter occurred uh the time spent on Advanced Care planning and a description of the Advanced Care planning dis uh topics that were discussed Advanced Care planning uses two billing codes only the first code is 9497 and that must always be entered first because it indicates the first 30 minutes of time that you're spending doing Advanced care plan Advanced Care planning you must complete a minimum of 16 minutes of discussion time in order to use the 9497 code when the discussion continues beyond the initial 30 minute period the practitioner should use the code 9498 for the next 30 minutes uh which is eligible once 16 minutes of that time has elapsed after that the practitioner should use 9498 for every 30 minute time interval uh once that time has been exhausted so these are different blocks of time you use the 9497 for the first 30 minutes and then for every 30 minutes after that you tack on the 9498 don't get confused in terms of the minimums uh really what you're focusing on are those 30 minute blocks of time in order to have time documentation count this is uh there's a a good encounter on the left and a not so great encounter on the right um on the left it counts when a practitioner is able to show that two distinct Services were provided and can claim credit for the palot of care services that were provided as you can see in the incorrect version neither a colleague nor anyone attempting to audit for documentation of this encounter would be able to tell how much of the encounter time was actually devoted to Advanced Care planning so you can have a pretty short chart note as long as you share that you have 110 minutes total with 50 minutes of that on Advanced Care planning that allows you to bill for both it's inevitable that sometimes paliative care providers have prolonged services that extend beyond the customary time for a patient encounter there are billing codes available that accommodate and recognize the value of those extended services we've outlined the requirements for you to help you understand when they can be used um and and by whom as well as a direction of what specific code should be used for an initial or subsequent Nursing Facility visit so this is something that's often done um in addition to Advanced Care planning all right so in terms of the brass tax on Advanced Care planning who can bill and how Physicians and non-physician practitioners and PPS can bill for Advanced Care planning uh Advanced Care planning has expanded from the Outpatient Clinic to now include Advanced Care planning that can be built in the hospital and Advanced Care planning that's built in the home setting and in certain circumstances build in t medicine there have been some recent revisions to direct supervision rules which actually expands some of these services to make it allowable for lcsws to actually Bill more easily for Advanced Care planning you'll see those here um people who have an NPI ultimately there are also incident two billing rules and incident two means that an advanced practitioner or an MD can start a visit a social worker can continue that visit for Advanced Care planning and that social worker can actually bill under the F The Physician billing uh NPI to for that Advanced Care planning and there are some rules around who actually qualifies as an NPP um so there I we can sense a link at the end of this in terms of who who qualifies for that but one of the groups who qualify for this incident to billing rule is a clinical social worker uh often times we don't know exactly what a clinical social worker uh really is um required document the required qualifications is that you really need to be in LCSW and have completed your training there are certain rules around coverage criteria for which lcsws can actually bill as and is considered a licensed clinical social worker but what's important here for Advanced Care planning is that these licensed clinical social workers can be paid at 75% of the clinical practitioners fee schedule for Advanced Care planning so so social workers can be doing this work um as a part of the team and be paid for it and this is really important when we think about what counts as Advanced Care planning um the accepted conversations that count under the reimbursement for ACP are discussions around health care options reviewing and refining goals for care deciding among options for treatment discussing documentation picking a proxy and completing forms so these could be a wide variety of discussions that one could have that can be reimbursed to count as Advanced Care planning again there are only two codes that are related to Advanced Care planning one is the first code and one is the addon time code this 9497 for the first 30 minutes and 9498 for the additional 30 minutes the this is uh around $85 so you see 86 for non facility $80 for facility for that first 30 minutes and then $75 for every additional 30 in order to use both codes together you need to have spent at least 45 minutes on an advanced care planning conversation so even if you spend three hours or four hours on Advanced Care planning you can continue adding up that time block for incident two billing and direct supervision this definition is that it requires a physician to be physically present in the office suite and immediately a available to furnish assistance and direction throughout uh that discussion so if an LCSW is having a discussion in the clinic The Physician needs to be in the clinic at that time doesn't necessarily be need to be in the same room one of the major changes during covid uh that is not going to be revised under the public health emergency is that direct supervision can be met if the supervising physician is immediately available to engage via FaceTime so you don't necessarily need to be in the same room or in the same office or physically present um as a social worker and a physician to have a social worker bill uh for Advanced Care planning under their physician oversight this is super important there are other things that are in the um uh that have been changed in terms of incident two billing so first there are no Medicare regulations that uh prohibit eligible distant site practitioners from billing for teleah Health Services provided incident to their services which means that you can be in someone's home as a social worker have an care planning conversation and Bill incident to your medical oversight if they're available via your phone under the new definition CMS actually has clarified that Services can be provided incident 2 um via tella health and that this and that a a physici only needs to be present virtually so now they actually have clear guidance around this in addition on the 2020 fee schedule they the CMS actually broadened modific to the medical record documentation requirements for Physicians and for npps and npps qualifying npps are now able uh to review and verify documentation entered into the medical record by members of the medical team um and that includes Advanced Care planning as well so lcsws are also able to review Advanced Care planning documents a couple of things to know about the uh audit process and Advanced Care planning billing and documentation number one first thing to know is that in terms of billing the uh folks who actually audit are called the max they're the Medicare administrative coordinators and they are the local folks who actually look at uh the billing practices in your area they make things called local coverage determinations and that's where the rules around documentation for Advanced Care planning lies uh which is sort of a challenge because that means it can sort of fairy everywhere you go um there are are really loose rules around Advanced Care planning so there's no specific format required by CMS for any of your documentation but you need to include these six things time spent in minutes the location of the service who received the service and that includes everyone people who were involved in the conversation or discussion summary of the discussion and if another provider performed the discussion identify the physician oversight you actually can make checklists there are a number of them out there and Doc phrases can be put into the electronic medical record to actually meet these requirements more easily I'd say really try and focus all of your time on the summary of the conversation rather than all of the uh uh other components that that can be tracked a little bit easier some frequently asked questions that I usually get first thing patients do not need to be present in order for you to bill for an advanced care planning conversation you can have an advanced care conversation with a surrogate and be reimbursed for that you can provide Advanced Care planning telephonically due to some of those oversight changes that we discussed and um there you can provide Advanced Care planning through telea Health but there are some restrictions around Audio Only more than one provider is able to bill for Advanced Care planning in any given period there are no maximums around how many times somebody can enter into an advanced care planning conversation so don't worry about whether or not somebody is getting two or three of them a week or even by two or three doctors um there is no limit to the which provider Specialties can actually build for Advanced Care planning so this can be a primary care provider an oncologist or a paliative care provider and there is no limit to the number of times that you can build this code or the amount of time that you can bill for it as long as you are documenting that you had that conversation for that length of time Advanced Care planning was also built to be Build Together with other routine visits like an evaluation and management code or an office visit so they are supposed to be bundled um start and stop time when that occurs is not necessary so if you do have an office visit where you are having Advanced Care planning you don't need to designate start and stop time you just need the total amount of time that you spent doing ACP that's a lot of stuff uh couple more things be the bottom bullet is the most important here because most paliative care social workers deliver care as part of a specialty team some patients may receive a bill for a co-pay or co- insurance if billing is not completely correct please remember to apply the correct modifier for Advanced Care planning which is this -33 so that Advanced Care planning can be counted as preventive even when people have a serious illness if a modifier is not applied some patients will receive up to a 20% co-pay it is important in your practice to have a script or a plan to discuss with the person um hopefully before the visit if a co-pay might be incurred for Advanced Care planning especially in the nature of social work that's really uh really important and it maintains trust with the patient and the family um key takeaways document your time when you're performing Advanced Care planning and not when you are charting a lot of the time um in doing audit reviews we saw a lot of two and three in the morning uh for the Advanced Care planning time I'm sure that's when the charting occurred not not when the conversation did Bill for both visits on the same day so if you have an office visit or a home visit um and an advanced care planning conversation bill for them both and um make sure you identify where the patient was when the care took place so if you're doing tella Health make sure you're documenting where the patient is not necessarily where you are use a checklist and Dot phrases to make sure you have those Six Bullets of information every time and make sure that you have a script for schedules schedulers and for social work staff for when somebody might receive an unnecessary co-pay make sure you follow the national consensus project clinical practice guidelines for when you you're having these goals of care conversations um and I know that kokua Ma spends a lot of time um helping support uh the actual discussions around Advanced Care planning um I provided some really helpful links here and I'll I'll share some additional information um and before I I go to questions about about the ACP billing um I'm going to touch really quickly on just checking time I'm going to touch really quickly on um the future so there are some things still in flux with this new um uh community- based pet of care benefit the paliative care benefit is going to be something that will be available um hopefully coming to a theater near you um for All Med Quest members so that is for all U members who are covered by Medicaid um over 65 under 65 and children and um this regardless of who their managed care plan is and so there are some goals that medquest has in developing a community- based p of care benefit um these are things that you probably are quite familiar with we want to make sure that we have Health Equity for people with serious illness and that people actually get the care that they want and that they need and that they're actually able to access care that's available to them and uh we also want to improve quality of life decrease symptom burden and also reduce all of the unnecessary in and out of the hospital that none of us uh really are excited about there's a timeline for this work we're sort of at the bottom we're currently negotiating with CMS Etc and um kokua and respecting choices who are also here on this call um as well as Julie poala are working to develop an implementation plan and we're hoping a little bit later this year we'll start to work on implementing this benefit so what do you need to know about reimbursement um reimbursement is for a bundle of services the services are for an for assessment for Clinical Services and for care coordination and communication including Advanced Care planning and it covers a full interdisciplinary team uh 247 and for children it also covers Child Life Specialists so that we can really make sure we're adapting uh services to kids we we are really focusing on this being a specialty care model and so this will require um paliative care specialty oversight for teams and the reimbursement structure is going to be a little bit of a blend between feif for service and your you know things that you see in hospice um and that means that there will be um a a it will be a a per member per month case rate payment where there's one payment that will be one code that will be build for all of the services that are delivered in that month um there's also a proposal for an additional assessment and that additional assessment is not Advanced Care planning it is more like a comprehensive assessment to better better understand a person's goals for care and so we are what we're hoping is that this comprehensive assessment for a person's goals for care coupled with somebody's Advanced Care planning conversation can really allow us to start to get a lot closer to what we have been hoping that Advanced Care planning can be that it's something that is about documentation and picking a proxy but it also is about clinical decision-making and really um uh documenting care needs so this is a little preview of how these codes will be laid out um there it there will be flexibility for those who are billing on a a CMS 1500 so for Professional Services um and for those who are billing on a ub4 which is sort of what you're seeing here um the the Revenue code set is for preh hospice paliative care services and would need to be build in combination with the CPT codes that are specific to the assessment and the delivery of services so you'll see those on the right for those who are in a professional practice and are seeking to really um start start to deliver paliative care services through a team you would need to then Bill a hick the hipic code but not the Revenue code um and they would end up uh processing the same so we're hoping to make it relatively simple and give a bit more uh technical uh guidance moving forward as we get more approvals coming um but this is sort of the preview of of what Pala of care billing and coding uh might look like in Hawaii all right um and with that I will take questions and please uh feel free to also email me with any questions afterward and I will make sure to get back to you well thank you very much Tori that was uh that was a a good start um I'm sure that there are questions out there folks can either put them into the chat or um people can raise their hand and and we can call on you there was um to start us out Melissa borquez had a question are payments paid under Medicare part A or Medicare or are paid under Medicare part A or Medicare Part B providers it's so funny Melissa I knew that someone was going to ask me that really early um this is really for Medicare Part B so for uh most of the providers that I know who are set up as a home health agency or set up as a hospice agency they use their Part B license in order to bill for Advanced Care planning okay good thank you um and you did share that uh these slides we can you can I can send them out to people so you can let me you can let me know folks and I can forward those on to you okay good two more questions I see um Melissa you also asked will billing codes also be credited to Quality metrics um like the medic care Stars metrics so it's interesting great question so Advanced Care planning is not part of the Medicare Stars metrics however Advanced Care planning is a required metric of all Hospital Systems in the country and it is a required metric um as part of the the dashboard for the Medicare incentive payment system so um this is something where um Hospital Systems actually get an increased Revenue if they hit their targets for certain things Advanced Care planning is one of them so there are quality incentives it's just not quite yet in the um uh in the Medicare Stars Arena um the other question is about the billing codes will the billing codes apply to all lines of business or Med Quest only for the Pala of care billing codes what is proposed is only for Med Quest however um what I am imagining is going to happen is really a transition or a change over for any of those commercial insurance companies or Medicare Advantage plans who are delivering or are planning to deliver a pet of care benefit or a service they're going to want to do everything the same way it's hard to do different things for different people well Tori you seem to have answered all questions which I find totally amazing since I'm already back on the wait what was that uh so oh well thank I hope so I hope I answered all your questions please let me know if there are any other questions that you have moving forward you know I I did get a a private question if you have an idea about the timing of our new Med Quest uh benefit I can tell you that people are really excited about that and um and then another question that I did get was difference between the initial assessment and the reassessment in the paliative care uh wait paliative care services benefit so Tori is teaching me to use the right terminology the med Quest benefit will be called the paliative care services benefit is that right that's right and I I'll give you the nerdy reason so this major category description is a description of the Revenue code and the Revenue code per CMS already already there is called preh hospice slash pallative care services so that's the term of the benefit because we're aligning it with um what the reimbursement really is called it's that's the only reason that we're calling it that um you can call it supportive care or whatever you'd really like to call it honestly as long as people want it and accept it and you build it as paliative care services that's fine um the the so so those are those are the the codes um so the assessment initial assessment and the reassessment for um those of you who deliver community- based P of care um or any type of P of care what you know is that this population is a population that changes and they have ongoing decline in function and so um through all of the research and literature um what we found is that you um need something that allows for a reassessment which um what we would say is once every three months or when goals for care change and that would then allow for us to have a more comprehensive conversation and an ass assessment when somebody maybe needs to graduate from pallative care and you need to coordinate care there or if somebody needs to move from paliative care to hospice or any of those transition points that allows you to um really reassess the person and determine if that's the right program or um a a configuration of services for them um so that's the difference between the initial and the reassessment um in terms of the timeline what we are hoping for is um to be able to implement or have a start by uh 1 one of of 24 the the so that we have an implementation period of of this year oh I had somehow understood it was um kind of as soon as it's approved no so we wait until just January of next year that's a I mean it's a longer conversation mostly to try and say that we want to make sure that it's set up and that we're not back reimbursing for things that weren't set up for um you know or optimized beforehand so I think that um what we want to do is really Implement as quickly as possible but make sure that there is enough time for folks on the provider side and on on the payer side to be able to uh get off the ground okay so I think you have heard Tori from a number of different um corners of our state that we are very excited about this benefit and people are really uh hoping that this will be coming soon and uh therefore you know and people are really interested in the whole thing so we we are of course hoping for sooner rather than later but uh but but but we're on board so good to know oh I'm um you know thank you very much I I think that um what I can share is that um Judy Moore Peterson and her policy team is working on this every single day and um we have a a really great collaboration with CMS and this is really the first time ever and so they have a lot of questions about how these things work even on their own in their own guidance um so it's been really fun to um have like a little joint research project however having a joint research project gets in the way of serving seriously ill patients and families and building our Workforce so um you know we're trying to hurry them along as well Brenda you asked a question you asked a question about whether or not the assessment can be done only over one day or over multiple days it can be done over multiple days it just needs to be completed I I hope that I hope that is a good response and to to clarify Advanced Care planning could be part of that assessment if they were the spe if there were additional as you laid out for us okay absolutely and then when somebody actually engages or is uh enrolled in paliative care services Advanced Care planning becomes part of that ongoing package of services so um we would expect that Advanced Care planning is then part of the ongoing um service great um this year the we there was a law path that allowed physician assistants to sign a post so how did they fit into this uh SCH Pas are would be able to offer the initial assessments as well so they would be able to deliver that initial assessment they're also able to be the oversight for an LCSW who is performing Advanced Care planning okay well Tori a I I think you've done an amazing job people have answered you know have lots of questions answered so um you know on behalf of kakal and the folks here in uh in Hawaii I'd really like to thank you for coming uh you feel free to stay Thank you for this great presentation and also for sharing this slides so that uh folks can follow up with other um with other questions and um Tori has graciously agreed for us to record this so this can be up on the YouTube channel as well so uh Tori thanks thank you very much thank you thanks for having me and and I do want to say thank you for all that you're you're doing to help Hawaii and we are all very clear that we would be the first state to have this paliative care services been benefits so it's uh that is really that is really great