Compensation based on Volume …
- Fee for Service
- Expensive In-Patient Hospital Stays
- Over Utilization of Services
- Disconnected “At Home” Care
- No Outcomes Measurements or Incentives
Outcome: High readmission rates, excess costs, clinical risks
Compensation based on Value…
- Fee for Total Episode
- Optimal Site of Service
- Appropriate Utilization of Services
- Virtual “At Home” Surveillance
- Documentation of Successful Outcomes
Outcome: Documented higher quality & lower cost of care
ValidCare Network Services
Are you ready to deliver Value-Based Surgical Care?
Surgery centers can shift significant orthopedic case volume from hospitals, delivering care at a lower total cost and better overall experience for the patient.
ValidCare provides surgery centers with the tools and solutions necessary to successfully capitalize on this opportunity:
- Align the economic interests of the surgery centers, physicians and other care givers
- Improve patient experience and power care coordination from “pre-hab” through “re-hab”
- Measure, benchmark & report network performance
- Must be performed by a physician or other qualified health care professional – CPT code 99091 specifies that the electronic data transmitted by the patient must be interpreted by a physician or other qualified health care professional. The American Medical Association defines this as “an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.” CMS current billing guidelines state that time counted toward CCM services generally refers to time spent by clinical staff furnishing care management services; however, CPT code 99091 refers to time spent by the practitioner.
- Billable with CCM, TCM & BHI – CMS is allowing CPT code 99091 to be billed once per patient during the same service period as chronic care management (CCM) (CPT codes 99487, 99489, and 99490), Transitional Care Management (TCM) (CPT codes 99495 and 99496), and behavioral health integration (BHI) services (CPT codes 99492, 99493, 99494, and 99484). CPT code 99091 should be billed no more than once every 30 days.
- Advance beneficiary consent required – CMS is requiring advance consent for remote patient monitoring. This must be documented in the patient health record.
- 30 Minute Minimum – CPT code 99091 specifies a minimum of 30 minutes of time that should be reported no more than once during a 30-day period. This requirement specifies time involved with data accession, review & interpretation, care plan modifications (including communication to the patient or caregiver) and associated documentation.
- Initiating Visit – A face-to-face visit is required for new patients or patients not seen by the billing practitioner within one year prior to billing CPT code 99091. This includes Annual Wellness Visits, Initial Preventive Physical Exams and other face-to-face visits performed by the billing practitioner.
- No chronic condition requirement
- No care planning requirement
- RPM can be billed by separate providers – i.e. Specialists can bill for RPM even if the PCP is billing for CCM. CCM can only be reported by one practitioner per month.
- Centers for Medicare & Medicaid Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10393.pdf
- Federal Register. https://www.federalregister.gov/documents/2017/11/15/2017-23953/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions