Reimbursement Scenarios

CMS has released its final rule for the 2020 Physician’s Fee Schedule.

We have previously covered how one can set up a chronic care management program in 5 steps. We have also covered the available CPT codes that can be used to bill for chronic care management, which also includes remote patient monitoring. If you want a condensed version of all that, 

DOWNLOAD THE 2019 REIMBURSEMENT GUIDE

(Summary of What CCM and RPM Entails)

If you want to see the changes enacted for 2020 and the exact reimbursement amounts you can expect, 

DOWNLOAD THE 2020 REIMBURSEMENT GUIDE 

(Actual Reimbursement Amounts Going Forward)

The great news is none of the existing CPT codes have been modified for 2020! So a provider organization or practice can use those codes to finance their CCM and RPM programs. Especially those who have not gotten into the habit of using those CPT codes, now would be the time, as they have remained the same for the next year. So this 2019 Reimbursement Guide is still applicable, that covers both Chronic Care Management (CCM) and Remote Patient Monitoring (RPM). It will allow you to better understand the nature of those two programs. But to see exactly what changes have been made, and what it means for the reimbursement amounts for 2020, see this guide

For a more detailed breakdown of that guide, keep on reading.

The only changes that have happened for 2020 are the inclusion of other codes to bill extra periods of time worked on a patient, and making the RPM codes furnishable via general supervision. It was only possible to furnish them via direct supervision prior.

Both changes are extremely beneficial. First, they do not displace any existing codes, thus organizations and clinicians alike do not need to relearn anything. The only thing they need to do is start familiarizing themselves with the existing CPT codes(as found on the reimbursement guide), and begin using them.  

Second, the new changes make it easier to implement the codes because of a more relaxed stance on supervision. They also allow more options when providing care as far as the time allotted to patient goes. We cover the changes below. Going forward in 2020, one can bookmark this page to see all CPT codes that are available to them (existing ones and new ones included). 

 
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Bonny
September 14, 2020 At 2:02 am

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I truly appreciate people like you! Take care!!

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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