Author Archives: Vignesh Eswaramoorthy

Medicare Advantage vs. Traditional Medicare: What’s Best for Seniors?

Traditional Medicare

Traditional Medicare, also known as Original Medicare, has been the foundation of senior healthcare in the U.S. since its inception in 1965. It consists of two parts:

  • Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and home health care.
  • Part B (Medical Insurance): Covers outpatient care, doctor services, preventive services, and some home health care.

Traditional Medicare operates on a fee-for-service basis, where beneficiaries can visit any healthcare provider that accepts Medicare. However, it does not cover all healthcare costs, leaving gaps such as prescription drugs (covered under Part D), dental, vision, and long-term care.

Medicare Advantage

Medicare Advantage is an alternative to Traditional Medicare. These plans are offered by private insurance companies approved by Medicare and must cover at least what Traditional Medicare covers, but often include additional benefits such as prescription drug coverage, dental, vision, hearing, and wellness programs.

Medicare Advantage plans usually operate as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which means that beneficiaries may have to use a network of doctors and hospitals and may need referrals to see specialists.

Medicare Advantage Care Management programs are initiatives designed to help Medicare Advantage (MA) plan beneficiaries manage their health, particularly those with chronic conditions or complex health needs. These programs aim to improve patient outcomes, enhance care coordination, and reduce healthcare costs by providing personalized care and support to beneficiaries.

Key Components of Medicare Advantage Care Management Programs

  1. Care Coordination
    • Primary Care Provider (PCP) Engagement: Care management programs often assign a primary care provider (PCP) to coordinate all aspects of a patient’s care. This includes managing referrals to specialists, ensuring follow-up appointments, and overseeing overall treatment plans.
    • Interdisciplinary Care Teams: These programs may involve a team of healthcare professionals, including doctors, nurses, pharmacists, social workers, and care managers, who work together to provide comprehensive care.
  2. Chronic Care Management
    • Disease-Specific Programs: Many care management programs focus on managing chronic conditions like diabetes, heart disease, COPD, and hypertension. These programs provide education, monitoring, and interventions tailored to the specific needs of patients with these conditions.
    • Telehealth and Remote Monitoring: MA plans often incorporate telehealth services and remote patient monitoring (RPM) to keep track of patient’s health status in real time, enabling timely interventions and reducing hospitalizations.
  3. Medication Management
    • Medication Reconciliation: Care managers review and reconcile medications to ensure patients are taking the right medications at the right times, minimizing the risk of adverse drug interactions.
    • Pharmacy Coordination: Programs may include coordination with pharmacies to streamline medication delivery and ensure that patients adhere to their prescribed treatment regimens.
  4. Personalized Care Plans
    • Individualized Plans: Each beneficiary receives a personalized care plan based on their specific health needs, preferences, and goals. These plans are regularly updated to reflect changes in the patient’s condition or treatment.
    • Patient and Family Engagement: Care management programs actively involve patients and their families in the care planning process, ensuring that the care provided aligns with the patient’s wishes and lifestyle.
  5. Preventive Care and Wellness Programs
    • Health Screenings and Vaccinations: MA plans may offer preventive care services, such as regular health screenings and vaccinations, to catch potential health issues early and prevent complications.
    • Wellness Programs: Many care management programs include wellness initiatives like fitness classes, nutritional counseling, and smoking cessation programs to promote healthier lifestyles among beneficiaries.
  6. Transition of Care
    • Post-Hospitalization Follow-Up: Care management programs often include follow-up care after hospitalizations to ensure that patients transition smoothly back to their homes and adhere to their post-discharge care plans.
    • Reducing Readmissions: By closely monitoring patients after discharge and providing necessary support, these programs aim to reduce hospital readmissions, which can be costly and detrimental to patient health.
  7. Home and Community-Based Services
    • In-Home Care: Some Medicare Advantage plans provide in-home care services, including home health visits, to support patients with mobility issues or those recovering from surgery.
    • Community Resources: Care management programs may connect patients with community resources, such as transportation services, meal delivery, and social support groups, to address social determinants of health.

Benefits of Medicare Advantage Care Management Programs

  • Improved Health Outcomes: By providing coordinated, comprehensive care, these programs help manage chronic conditions more effectively, leading to better overall health outcomes for beneficiaries.
  • Enhanced Patient Satisfaction: Personalized care plans and active patient engagement contribute to higher satisfaction rates among Medicare Advantage enrollees.
  • Cost Savings: Effective care management can reduce the need for emergency room visits and hospitalizations, leading to lower healthcare costs for both beneficiaries and Medicare Advantage plans.
  • Preventive Care Emphasis: By focusing on preventive care and early intervention, these programs help to identify and address health issues before they become serious, further improving patient outcomes.

Market Data and Statistics: A Comparative Look

Enrollment Trends

  • Growing Popularity of Medicare Advantage: As of 2024, nearly 50% of all Medicare beneficiaries (around 31 million people) are enrolled in Medicare Advantage plans. This represents a significant increase from 19% in 2007, reflecting a growing preference for the additional benefits and coordinated care that Medicare Advantage offers.
  • Traditional Medicare Enrollment: Despite the rise of Medicare Advantage, approximately 30 million seniors remain enrolled in Traditional Medicare, valuing its flexibility and extensive provider network.

Costs and Out-of-pocket Expenses

  • Premiums and Out-of-Pocket Costs: Traditional Medicare beneficiaries typically pay a premium for Part B (around $164.90 per month in 2024) and may purchase supplemental insurance (Medigap) to cover out-of-pocket costs like deductibles, coinsurance, and copayments. Medigap premiums can range widely but often average around $150 per month.
  • Medicare Advantage Costs: Medicare Advantage plans often have lower or even $0 premiums, but they may come with higher out-of-pocket costs, such as copayments, coinsurance, and deductibles. These plans also have a maximum out-of-pocket limit (averaging around $8,850 in 2024), which Traditional Medicare does not offer.

Access to Care

  • Provider Networks: One of the primary differences is the provider network. Traditional Medicare allows access to any doctor or hospital that accepts Medicare, which is virtually all providers in the country. In contrast, Medicare Advantage plans typically require beneficiaries to use a network of providers, which can be more restrictive.
  • Care Coordination: Medicare Advantage plans often include care coordination services, where a primary care physician manages a beneficiary’s care, potentially leading to better health outcomes. Traditional Medicare does not offer this feature, leaving care coordination up to the patient and their providers.

Coverage for Additional Services

  • Prescription Drugs: Traditional Medicare beneficiaries must enroll in a separate Part D plan to receive prescription drug coverage. Medicare Advantage plans usually include Part D coverage as part of the plan.
  • Dental, Vision, and Hearing: Medicare Advantage plans often include coverage for dental, vision, and hearing services—benefits not typically covered by Traditional Medicare.
  • Wellness Programs: Many Medicare Advantage plans offer additional perks, such as gym memberships, transportation services, and wellness programs, which are not available through Traditional Medicare.

Pros and Cons of Medicare Advantage vs. Traditional Medicare

Medicare Advantage: Pros and Cons

Pros:

  • Comprehensive Coverage: Medicare Advantage plans often include additional benefits such as prescription drugs, dental, vision, and wellness programs.
  • Lower Premiums: Many Medicare Advantage plans offer lower premiums, with some even offering $0 premium options.
  • Care Coordination: These plans often provide care coordination services, which can lead to better management of chronic conditions.

Cons:

  • Network Restrictions: Beneficiaries are typically required to use a network of providers, which can limit access to preferred doctors and hospitals.
  • Out-of-Pocket Costs: Although premiums may be lower, out-of-pocket costs for services can be higher, especially if care is received outside the network.
  • Complexity: Medicare Advantage plans can be complex, with varying rules and costs that may change annually.

Traditional Medicare: Pros and Cons

Pros:

  • Flexibility: Beneficiaries can visit any doctor or hospital that accepts Medicare, providing broad access to care.
  • Stable Coverage: Traditional Medicare benefits are consistent and do not change based on geographic location or network.
  • Supplemental Coverage: Medigap policies are available to help cover out-of-pocket costs, reducing financial risk.

Cons:

  • Higher Premiums: The combination of Part B premiums and Medigap premiums can result in higher overall costs.
  • No Cap on Out-of-Pocket Spending: Traditional Medicare does not have a maximum out-of-pocket limit, which can expose beneficiaries to high costs in case of serious illness.
  • Limited Additional Benefits: Traditional Medicare does not cover services like dental, vision, hearing, or wellness programs.

What’s Best for Seniors?

Deciding between Medicare Advantage and Traditional Medicare depends on individual circumstances, including health needs, financial situation, and personal preferences.

Consider Medicare Advantage if:

  • You prefer a plan with a lower premium that includes additional benefits.
  • You value the convenience of having all your healthcare needs covered under one plan, including prescription drugs.
  • You are comfortable using a network of providers and are looking for care coordination services.

Consider Traditional Medicare if:

  • You want the flexibility to choose any doctor or hospital that accepts Medicare.
  • You are willing to pay higher premiums for the stability of coverage and the option to purchase a Medigap policy to minimize out-of-pocket costs.
  • You prefer to avoid the restrictions and complexity of network-based care.

Conclusion

The choice between Medicare Advantage and Traditional Medicare is a significant decision for seniors in the United States. With nearly 50% of Medicare beneficiaries now enrolled in Medicare Advantage plans, it’s clear that the additional benefits and lower premiums are appealing to many. However, Traditional Medicare’s flexibility and stability continue to attract millions of seniors who prioritize broad access to care.

Medicare Advantage Care Management programs play a crucial role in delivering high-quality, personalized care to beneficiaries, particularly those with chronic or complex health needs. Through coordinated care, chronic care management, medication oversight, and preventive services, these programs aim to enhance patient outcomes, reduce healthcare costs, and improve the overall experience for Medicare Advantage enrollees. As these programs continue to evolve, they will likely become even more integral to the success of Medicare Advantage plans in providing value-based care.

Ultimately, the best choice depends on individual needs and circumstances. By carefully considering the pros and cons of each option, along with the latest market data and Medicare statistics, seniors can make an informed decision that best suits their healthcare needs and financial situation.

As the healthcare landscape continues to evolve, it’s crucial for seniors to stay informed about their Medicare options and to re-evaluate their coverage annually during the open enrollment period to ensure it continues to meet their needs.

CMS’s Journey To Value-Based Care

Most people think of CMS (Centers for Medicare & Medicaid Services) as an insurance company that covers individual services provided by physicians, FQHCs, hospitals, and other health care providers. Some people even think of it as a policy-writing agency for Medicare. It is true that CMS reimburses providers for services to millions of individual beneficiaries. However, since the Affordable Care Act came into action in 2010, CMS has been developing focused payment strategies that shift from fee for services to value-based care and a focus on population health. 

Today, CMS’s second-highest strategic priority is prevention and population health. To this day, the agency is engaged in numerous activities to promote effective prevention of chronic diseases and not just its treatment.

In 2011, the federal government reported that fewer than half of all adults aged 65+ were regular in checking the core set of recommended preventive services. The Affordable Care Act took a big step towards improving the access to preventive care by eliminating out-of-pocket costs for these preventive services in most insurance markets. This resulted in guaranteed access to preventive services like diabetes screening and cervical cancer screening to almost 137 Million Americans without cost-sharing.

Despite improved access to care, the use of preventive services among seniors with traditional Medicare coverage has not changed significantly. There are several hindrances that inhibit the greater uptake of preventive services. A 2014 survey reveals that only 43% of adults were aware of the new clinical preventive benefits provided by the Affordable Care Act. Of those who were aware of the services, 18% cited cost as a barrier, even though the Affordable Care Act eliminated co-payments for preventive services. 

Another obstacle is that many Americans believe that preventive services are not important. Thus, even though many cost barriers have been removed, many Americans still might not perceive preventive services as valuable to their health and well-being. This mindset needs to change. 

Shifting the paradigm of preventive care requires CMS and other payers to provide incentives beyond individual services to broader value-based and lifestyle interventions that can change population outcomes. To address this issue, CMMI has developed 2 payment models:

(1) The Million Hearts Cardiovascular Risk Reduction Model:

Million hearts model

This model associates payment with population-based risk reduction. It is expected to reach over 3.3 million Medicare fee-for-service beneficiaries and involve nearly 20,000 health care practitioners by December 2021.

(2) The Medicare Diabetes Prevention Program:

Medicare Diabetes Prevention Program

This program ties payments to the achievement of weight loss through evidence-based lifestyle intervention.

CMS collaborated with sister agencies such as the Centers for Disease Control and Prevention (CDC) to develop these population health models, and they are good examples of how CMMI is using the Medicare payment structure to improve prevention and population health.

These path-breaking innovations offer an opportunity for CMS to test payment models that emphasize payment for population health outcomes rather than just individual outcomes, with the goal of better care and a healthier population.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298510/#bibr11-0033354916681508

https://innovation.cms.gov/innovation-models/million-hearts-cvdrrm#:~:text=The%20Million%20Hearts%C2%AE%3A%20CVD%20Risk%20Reduction%20Model%20is%20expected,and%20end%20by%20December%202021 

CMS expands Telehealth Services to Deliver Care Safely during COVID-19 and Beyond

During the COVID-19 pandemic, CMS has taken the necessary steps to make it easier to provide quality care through telehealth services. This unprecedented action by CMS has encouraged healthcare providers to adopt and use telehealth as a way to safely provide care to their patients in situations like medication consultation, eye exams, nutrition counseling, behavioral health counseling, and routine health check-ups like annual wellness visits. Past data have shown telehealth to be an effective medium for patients to access healthcare providers especially for managing chronic conditions like diabetes, asthma or to obtain mental health counseling.

Advantages of CMS changes to Telehealth:

telehealth reimbursement codes

Telehealth services made permanent post-COVID-19:

CMS has announced that 60 of the 144 telehealth services that were newly offered during the pandemic will become permanent. This includes services for cognitive assessment, psychological and neuropsychological testing, and custodial care services for established patients.

virtual healthcare

They have also finalized the decision that direct supervision in telehealth visits can be provided with interactive audio and video technology through the end of the year until December 2021. 

 

CPT Code

Services

Description

77427

Radiation management

It is reported once for every five fractions or treatment sessions regardless of the actual time period in which the services are furnished. The services need not be furnished on consecutive days.

90853

Group psychotherapy

Group psychotherapy including interpersonal interactions and support with several patients; typically 45 to 60 minutes in length.

90953

End-stage renal disease, one visit per month, ages 2 and younger

End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, etc.

90959

End-stage renal disease, one visit per month, ages 12-19

End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth 

90962

End-stage renal disease, one visit per month, ages 20 and older

With 1 face-to-face physician visit per month

92057

Speech/hearing therapy

Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual

92521

Evaluation of speech fluency

Evaluation of speech fluency (e.g., stuttering, cluttering)

92522

Evaluation speech production

Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) 

92523

Speech sound language comprehension

Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)

92524

Behavioral quality voice analysis

Behavioral and qualitative analysis of voice and resonance.

96130

Psychological test Evaluation Phys/qhp 1st

Psychological testing evaluation services by a physician or other qualified healthcare professional, including the integration of patient data, interpretation of standardized test results and clinical data

96131

Psychological test evaluation phys/qhp ea

Providers should now use CPT code 96130 to bill for the first hour of psychological testing evaluation services and 96131 for each additional hour

96132

Neuropsychological testing evaluation phys/qhp 1st

Neuropsychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour

96133

Neuropsychological testing evaluation phys/qhp ea

The first hour of neuropsychological evaluation is billed using 96132 and each additional hour needed to complete the service is billed with code 96133

96136

Psychological and neurological testing phy/qhp 1s

Psychological or neuropsychological test administration/scoring by physician or other qualified healthcare professional, two or more tests, any method; first 30 minutes

96137

Psychological and neurological testing phy/qhp ea

Similar to 96136. This code is used for each additional hour.

96138

Psychological and neurological tech phy/qhp ea

Psychological or neuropsychological test administration/scoring by technician, two or more tests, any method; first 30 minutes

96139

Psychological and neurological testing tech ea

Similar to 96138. 

 97110

Therapeutic exercises

Foundational, occupational therapy exercises that are designed to improve a patient’s strength, range of motion, endurance, or flexibility.

97112

Neuromuscular re-education

Specific exercises or activities performed and for what purpose, neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, and/or posture.

97116

Gait training therapy

Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing). 

97161

Physical therapy evaluation 

Physical therapy evaluation of low complexity, 20 min

97162

Physical therapy evaluation 

Physical therapy evaluation moderate complexity, 30 min

97163

Physical therapy evaluation 

Physical therapy evaluation moderate complexity, 30 min

97164

Physical therapy evaluation

Physical therapy re-evaluation establish plan care

97165

Occupational therapy evaluation 

Occupational therapy evaluation low complexity, 30 min

97166

Occupational therapy evaluation 

Occupational therapy evaluation moderate complexity, 45 min

97167

Occupational therapy evaluation 

Occupational therapy evaluation high complexity, 60 min

97168

Occupational therapy 

Occupational therapy re-evaluation establish plan care

97535

Self-care management training

Direct one-on-one supervision and instruction regarding activities of daily living related to the patient’s health and hygiene.

97750

Physical performance test

Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.

97755

Assistive technology assessment

This procedure is used by the provider to assess the suitability and benefits of technological interfaces that will help restore, augment, or compensate for existing functional ability in the patient.

97760

Orthotic management and training 1st en

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes.

97761

Prosthetic training 1st enc

Prosthetic training, upper and/or lower extremities, initial prosthetic encounter, each 15 minutes

99217

Observation care discharge

This code is used to report all services provided to a patient discharged from outpatient hospital “observation status” if the discharge is on a date other than the initial date of “observation status

99218

Initial observation care

The first visit of the patient’s admission for outpatient hospital observation care by the Admitting/Supervising Physician or Other Qualified Healthcare Professional. Typically, 30 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99219

Initial observation care

Similar to 99218 but, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99220

Initial observation care

Similar to 99218 but, 70  minutes are spent at the bedside and on the patient’s hospital floor or unit.

99221

Initial hospital care

Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician.

99222

Initial hospital care

Similar to 99221

99223

Initial hospital care

Similar to 99221

99234

Observation/hospital same date

Observation or inpatient care, are used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.

99235

Observation/hospital same date

Observation or inpatient care is used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.

99236

Observation/hospital same date

Observation or inpatient care is used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.

99238

Hospital discharge day

Used when time spent is less than 30 minutes on the discharge process in face-to-face evaluation.

99239

Hospital discharge day

Used when time spent is greater than 30 minutes on the discharge process in face-to-face evaluation.

99281

Emergency department visit

Requires these 3 key components: A problem-focused history; A problem-focused examination; and Straightforward medical decision-making. Usually, the presenting problem(s) are self-limited or minor.

99282

Emergency department visit

Requires these 3 key components: An expanded problem-focused history; An expanded problem-focused examination; and Medical decision-making of low complexity. Usually, the presenting problem(s) are of low to moderate severity.

99283

Emergency department visit

Requires these 3 key components: An expanded problem-focused history; An expanded problem-focused examination; and Medical decision-making of moderate complexity. Usually, the presenting problem(s) are of moderate severity.

99284

Emergency department visit

Requires these 3 key components: A detailed history; A detailed examination; and Medical decision-making of moderate complexity. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

99285

Emergency department visit

Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

99291

Critical care first hour

It is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date

99292

Critical care additional 30 mins

Code 99292 (critical care, each additional 30 minutes) is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care.

99304

Nursing facility care initial

The problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.

  99305

Nursing facility care initial

The problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.

99306

Nursing facility care initial

The problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit.

99315

Nursing facility discharge day

99315 is for discharge day management 30 minutes or less

99316

Nursing facility discharge day

This code is for discharge day management over 30 minutes

99327

Domiciliary or rest home visit new patient

Domiciliary or rest home visit for the evaluation and management of a new patient. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.

99328

Domiciliary or rest home visit new patient

Code used for Evaluation and Management / Domiciliary, rest home (boarding home) or custodial care services. The general guidance for this code is that it is used for new patient assisted living visits, typically 75 minutes. 

99334

Domiciliary or rest home visit established patient

This code 99334 is used to reflect the domiciliary or rest home visit for the E/M of an established patient

99335

Domiciliary or rest home visit established patient

Similar to 99334

99336

Domiciliary or rest home visit established patient

Similar to 99334

99337

Domiciliary or rest home visit established patient

Domiciliary or rest home visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family

99341

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home. Level 1 new patient home visit.

99342

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home. Level 2 new patient home visit.

99343

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home. Level 3 new patient home visit.

99344

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home. Level 4 new patient home visit.

99345

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home.Level 5 new patient home visit.

99347

Home visit established patient

Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components.  A problem-focused interval history; a problem-focused examination; and straightforward medical decision making. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99348

Home visit established patient

Similar to CPT Code 99348. Typically, 25 minutes are spent face-to-face with the patient and/or family.

99349

Home visit established patient

Similar to CPT Code 99348. Typically, 40 minutes are spent face-to-face with the patient and/or family.

99350

Home visit established patient

Similar to CPT Code 99348. Typically, 60 minutes are spent face-to-face with the patient and/or family.

99468

Neonatal critical care initial

Services of directing the inpatient care of a critically ill neonate or infant 28 days or younger. 

99469

Neonatal critical care initial

Services of directing the inpatient care of a critically ill neonate or infant 28 days or younger. 

99471

Pediatric critical care initial

Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

99472

Pediatric critical care initial

Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

99473

Self-measurement of blood pressure at home education/training

Code 99473 represents the work of training the patient and calibrating the device,

99475

Pediatric critical care ages 2-5 initial

Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age

99476

Pediatric critical care ages 2-5 subsequent

Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age

99477

Initial day of hospital care for neonatal care

Initial hospital care of the neonate (28 days or younger) who is not critically ill but requires intensive observation, frequent interventions, and other intensive care services.

99478

Ic low-birthweight infant

Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant( < 1500 gm)

99479

Ic low-birthweight infant < 1500-2500 g subsequent

Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant( 1500 gm-2500g)

99480

Ic infant pbw 2501-5000 g subsequent

Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant(2501g-5000g)

99483

Assessment and care plan cognitive impairment

Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home

The ongoing pandemic has resulted in an increased workload for healthcare providers across the country. Incorporating telehealth software into an existing practice can allow providers to virtually connect with patients. This can relieve the strain on practice while introducing an additional revenue stream.

HealthViewX Telehealth/Telemedicine Platform helps health systems to align clinical, financial, and operational goals by providing high-quality remote care and enhancing patient-physician collaborations.

References: https://www.beckershospitalreview.com/telehealth/cms-adds-85-more-medicare-services-covered-under-telehealth.html

Leveraging AI in Healthcare Technologies to Optimize Chronic Pain Management

Introduction

In the world of healthcare, we’re seeing some pretty big changes thanks to artificial intelligence (AI). One key area where AI is really making a difference is in managing chronic pain. A lot of people around the globe suffer from chronic pain, which creates huge challenges not just for them personally but also economically. The usual ways of dealing with pain don’t always work well for everyone. But now, AI is stepping in and offering new hope.

With tools like predictive diagnostics, natural language processing, and even robotics powered by AI are changing how doctors approach pain management. These tech advancements mean that diagnosing problems can be more accurate than ever before; they help keep patients involved in their own care and make sure treatments are tailored specifically to what each person needs. This move towards using AI in health stuff looks really promising for helping folks deal with chronic pain better.

The Evolution of AI in Healthcare

In the healthcare world, artificial intelligence has really changed things up. With stuff like generative AI and neural networks leading the charge, we’re seeing some cool new tech in medicine. This means doctors can figure out what’s wrong with you more accurately, come up with better ways to treat you, and overall take care of patients better. By feeding these AI systems a ton of information, they get smarter over time. This is especially good news for folks dealing with chronic pain because it’s helping find better ways to manage it.

The beginning of AI in medicine

The journey of AI in healthcare started when people working on computer science and deep learning saw how it could change the way we treat illnesses. They created computer programs that could go through a lot of information quickly, making it easier to figure out what’s wrong with someone and how to treat them. By using deep learning, which involves complex artificial neural networks, the power of ai systems got even better for medical use. This was really the start of using AI in medicine, paving the way for today’s progress in managing long-lasting pain.

Current advancements in AI for healthcare

Right now, AI is making a big difference in many areas of healthcare, like helping people who suffer from long-term pain. By using machine learning, computers can look through huge amounts of data to help come up with treatment plans that are tailored just for them. Deep neural networks, which are really good at dealing with complicated information, play a key role in pushing forward the use of AI in healthcare. With these technologies at work, doctors can better manage pain for their patients, leading to better health results and higher quality care overall.

Understanding Chronic Pain and Its Impact

Chronic pain is a big health problem that touches the lives of millions around the globe. It’s when you’re in pain for more than three months straight. With chronic pain, life can get pretty tough – it can make your quality of life worse, cut down on how much work you can do, and bump up what you spend on healthcare. Figuring out how to manage this kind of pain isn’t easy because everyone needs something different to help them feel better. By bringing AI technology into the picture for managing pain, there’s a chance to make treatment plans better suited for each person dealing with chronic pain and possibly improve their situation.

Definition and types of chronic pain

Chronic pain covers a bunch of different health issues and gets sorted by what causes it or where you feel it. You’ve got things like nerve pain, muscle and bone pain, and really bad headaches as some common kinds. Treating each kind needs its own plan. With the help of AI technology, figuring out which type of pain someone has becomes easier, leading to treatments that are more tailored to the individual. By looking at lots of data from different places, AI helps doctors make better choices in how they handle chronic for patients making their care better overall. On top of this using operations research can make sure resources are used in the best way possible so managing chronic doesn’t waste time or money.

The socio-economic impact of chronic pain

In places like the United States, chronic pain really takes a toll not just on people’s health but also hits hard economically. About 1 in every 5 people live with this kind of pain, leading to huge amounts of money spent on healthcare and even more lost because folks can’t work as much or at all. It’s not only about the bills for doctors and medicine; it affects whether someone can do their job, enjoy day-to-day life, or feel happy overall. By using AI technology to manage chronic pain better, doctors could make treatments more effective and lessen how much chronic pain costs everyone involved – from those suffering directly from it to society in general.

AI Technologies in Pain Management

AI technologies are changing the way we manage pain by making diagnosis, treatment planning, and how we engage with patients better. With AI algorithms, predictive diagnostics can look through patient data to spot patterns and guess how well treatments might work. Thanks to natural language processing, ai systems can make sense of what patients say in their reports which helps doctors come up with care plans that are just right for each person. Robotics is also playing a big role in physical therapy and rehab by offering precise help exactly where it’s needed. All these advancements mean people dealing with pain get better care and see improved results from their treatments.

Machine Learning for predictive diagnostics

In the world of pain management, machine learning is playing a big role in creating models that can guess how well different treatments might work. These models look at things like what’s happened to the patient before, their symptoms, and results from tests to find patterns and make predictions about what treatments could be best. With machine learning, doctors have a better shot at choosing the right treatment for each person. This way, they can come up with care plans that are tailored just for them, making it more likely for patients to get better faster and helping manage pain in smarter ways.

Natural Language Processing for patient reports

In the world of healthcare, especially when it comes to managing pain, natural language processing (NLP) is making a big difference. It’s being used to go through what patients say and help doctors and nurses understand them better. With NLP, all those notes in electronic health records or the symptoms patients talk about can be quickly looked into by computers. This way, healthcare workers can spot trends or important bits of information that might help come up with treatments that are just right for each person. By combining NLP with speech recognition technology, AI systems are stepping in to make conversations between people seeking care and their caregivers smoother. This not only makes things more efficient but also helps folks feel more involved in handling their pain.

Robotics in Physical Therapy and Rehabilitation

In the world of pain management, robotics is making a huge difference in how physical therapy and rehabilitation are done. With the help of AI systems, these robots can offer very specific help that’s just right for what each person needs to feel better and recover faster. They’re smart enough to adjust their methods based on what works best for an individual patient, giving them a custom treatment plan. This blend of robotics with AI technology means doctors can make rehab programs much more effective at managing pain and helping patients get back on their feet quicker, all while boosting the quality of care they provide.

Case Studies: AI Success Stories in Chronic Pain Management

Through different examples, it’s clear that using AI in managing long-term pain works well. One area where AI shines is in precision medicine. Here, AI looks closely at each patient’s information to figure out the best treatment plan for them based on their specific traits. By using AI, doctors can create personalized treatment plans that really fit what each patient needs, making pain management better and patients happier. These examples show how powerful AI could be in changing how we handle chronic pain.

Implementing AI for Precision Medicine

In the world of healthcare, precision medicine is quickly changing how we approach treatment, making it more personal by looking at what makes each person unique. With a big focus on chronic pain management, AI is stepping up as a key player. It looks closely at heaps of information about patients – like their genes, past health issues, and how they’ve responded to treatments before – to figure out which treatment might work best for them. By bringing together big data and AI tools, doctors can now rely on solid facts to decide the best way to manage someone’s pain, leading to better results for patients.

Virtual reality as a pain management tool

Virtual reality, or VR for short, is starting to show a lot of promise in helping people manage pain. By putting patients into virtual worlds, it helps take their mind off the pain and gives them a feeling of calm and comfort. With VR, experiences can be customized based on what each person likes, making it more likely they’ll stick with it and find relief from their pain. On top of that, using VR might mean people don’t need to rely as much on strong painkillers that come with heavy side effects. As this technology gets better over time, we’re looking at VR playing a big role in making life easier for folks dealing with long-term pain.

Challenges and Considerations

AI technologies in healthcare show a lot of promise for making chronic pain management better. But, there are some big hurdles and things to think about. When it comes to using AI for health, we’ve got to be really careful about ethical issues. This includes worrying about bias and the moral questions that come up with artificial general intelligence. On top of that, keeping patient information safe is super important, so data privacy and security have to be strong. It’s also crucial to make sure there’s no gap between what AI can do and how doctors actually use it in their work. We need to ensure healthcare professionals know enough and have the right skills to use AI technologies well.

Ethical concerns in using AI for health

When we talk about using AI in healthcare, there are some big ethical questions that pop up and really need our attention. For starters, there’s a worry that AI might not treat everyone the same because of bias in its programming. This could mean unfair health outcomes for certain groups of people. To avoid this, it’s super important to make sure these ai systems learn from data that reflects all kinds of different folks.

Then there’s something called artificial general intelligence – basically when AI gets as smart as humans. We’ve got to think hard about what this means for who’s responsible when things go wrong, how clear they are about what they’re doing, and whether we might end up losing control over these technologies.

As ai systems keep getting better and smarter, making sure we have strong ethical rules is key so everything goes smoothly in healthcare.

Data privacy and security

When it comes to using AI for managing chronic pain in healthcare, keeping patient data safe and private is super important. This information is really personal, so we have to make sure only the right people can get to it. To do this, strong security steps like making data unreadable (encryption) and controlling who can see what (access controls) are a must-have. Also, following rules about protecting patient info is key—like the Health Insurance Portability and Accountability Act (HIPAA) in the United States. Healthcare places and companies that make AI need to work closely together. They should share data safely and stick to strict privacy rules. By putting data privacy and security first, patients can feel good about using AI technologies for their chronic pain management in the United States.

Bridging the gap between AI potential and clinical practice

AI could really change the game for managing long-term pain, but there’s a big step to take from what it can do to actually using it in doctor’s offices. For this tech to work well, doctors and nurses need to know how they can use AI tools and understand the info these tools give them. To get there, we should set up training programs so healthcare workers get the hang of AI stuff and make smart choices when treating patients with it. By working together with experts in AI, healthcare folks can help create solutions that fit right into their day-to-day tasks without causing any hiccups. With everyone on board and informed, we’ll be able to unlock all that AI has to offer for people dealing with chronic pain.

The Future of AI in Managing Chronic Pain

The future looks bright for using AI to handle long-term pain. By looking at big sets of data, predictive analytics can figure out patterns and guess how different treatments will work on individuals. With the help of smart gadgets and sensors that you wear, ai systems can keep an eye on how much pain someone is feeling, their physical activity, and other important info as it happens. This information lets us give personalized advice right when it’s needed most to better manage pain. Thanks to predictive analytics and wearable tech working together with AI systems, we’re moving towards a big change in managing chronic pain which could really make life better for people dealing with it every day.

Predictive analytics for personalized treatment plans

With the help of machine learning and AI systems, there’s a big chance to make treatment plans that really fit people who deal with chronic pain all the time. By looking into lots of data, which includes what patients say, their medical information, and how these smart computer programs learn over time, we can spot trends and guess how different treatments might work for someone. This means doctors can come up with care plans that are just right for each person’s unique situation, making it easier to handle their pain. On top of this, predictive analytics is good at spotting things that might cause chronic pain before it even starts. So by using these advanced tools like AI and machine learning in healthcare settings helps those suffering from constant pain get better support tailored just for them.

Integrating AI with wearable technology

Combining AI with wearable tech opens up new ways to handle chronic pain. With gadgets like smartwatches or sensors, we can track how much pain someone’s feeling, how active they are, their sleep habits, and more in real time. By using AI to look at this info, it can give advice that’s tailored just for them on how to manage their pain better. For instance, based on the levels of activity and patterns of pain a person has, AI might suggest changing up daily activities or trying out certain exercises or ways to relax. This mix of wearable technology and AI could really help people dealing with chronic pain take control and make their lives better.

Patient-Centered AI Approaches

To really make a difference in managing long-term pain, it’s crucial to put the focus on what patients need and want. With AI systems, we can do just that by creating care plans tailored specifically for each person. This way, folks dealing with chronic pain can get more involved in their treatment, receiving updates and support when they need it most. On top of this, AI helps keep a steady conversation going between patients and their doctors. This means treatments can be tweaked as needed based on real-time feedback. By keeping the patient at the heart of everything, using ai systems leads to better results all around – making care more effective and centered around those who matter most.

Enhancing patient engagement through AI

AI can really help out with managing chronic pain by making it easier for patients to stay involved. With the use of AI systems, doctors and other healthcare workers can offer care that’s tailored just right and comes at the perfect time, which makes treatment work better and keeps patients happier. Through things like chatbots or virtual helpers powered by AI, people can get answers, find resources, or have someone to talk to right away without always having to go see their doctor in person. Plus, AI has this cool ability to look through stuff patients record themselves – like how they’re feeling each day or what activities they’ve been doing – so it can give advice that’s really meant just for them. By giving patients these tools driven by AI technology, they play a bigger role in handling their pain effectively which means sticking closer to their treatment plans and seeing better results overall.

Feedback loops between patients and AI systems

For managing chronic pain better, it’s really important to have a good back-and-forth between patients and AI systems. By always gathering data that patients provide and looking into it closely, AI can offer help right when it’s needed. For instance, things you wear like fitness trackers can keep an eye on how much pain you’re feeling, how active you are, and your sleep habits. Then, AI takes this info to figure out what might be causing more pain or what makes it better. This helps in giving advice that’s just for you. On top of this, these feedback loops let doctors keep track of how well treatments are working so they can make changes if needed quickly and see which methods work best. When patients work together with AI systems through these loops, dealing with chronic pain becomes a team effort which leads to getting better results for the patient.

Regulatory Landscape for AI in Healthcare

In the world of healthcare, rules about AI are changing to make sure patients stay safe and their private info is kept secret. Right now, there are some rules like HIPAA in the United States that say how patient data can be collected, stored, and used. These rules help keep patient information safe and secure. But as AI gets better and does more things in healthcare, we’re starting to see new rules made just for AI use. Looking ahead, it’s likely that these new guidelines will focus on making algorithms clear to understand while also tackling issues like bias prevention and thinking carefully about how using AI affects patient care.

Current regulations and standards

In the United States, rules and standards are super important for making sure AI is used safely and ethically in healthcare. The Health Insurance Portability and Accountability Act (HIPAA) lays down the law on how patient data should be handled – it’s all about keeping patient information private and secure. These rules require that certain steps are taken to protect this info. On top of that, groups like the Food and Drug Administration (FDA) keep an eye on AI medical devices and apps to make sure they’re up to snuff. For those working with healthcare organizations or providing AI tech, sticking to these guidelines is key for using AI responsibly, especially when it comes to managing chronic pain or other health issues.

Future directions for policy and compliance

With AI getting better and faster in the healthcare world, there’s a big need to think about what rules and guidelines we should follow. As these AI technologies keep changing, new kinds of rules that focus just on how we use AI in healthcare are starting to pop up. Looking ahead, there are a few important things these future guidelines will probably cover.

For starters, it’ll be really important for everyone to clearly see and understand how these algorithms work when they’re used for taking care of patients. Making everything more open will help doctors and their patients get why an algorithm suggests one thing over another. Then, there’s the issue of making sure no one is left out because of unfair biases hidden within these algorithms; so figuring out ways to stop this bias is key if we want everyone to get fair treatment.

Lastly, keeping an eye on ai systems regularly will make sure they stay in line with any new rules or standards as they come along. By tackling these issues head-on now,the health sector can really make the most outof using ai while also keeping patient safetyand privacy at the forefront.

Conclusion

In the world of healthcare, AI is changing how we handle chronic pain by creating tailored treatment plans and making it easier for patients to get involved. With AI getting better over time, it’s leading to smarter predictions and working smoothly with wearable tech. But, we’ve got to keep a close eye on ethics and keeping information safe so that AI can really make a difference in clinical settings. Looking ahead, there’s a lot of hope for using AI to improve care for chronic pain through exact treatments and virtual reality tools. By focusing on what patients need from AI technology, we’re looking at improving life quality for those dealing with chronic pain.

Frequently Asked Questions

How can AI improve the quality of life for chronic pain sufferers?

AI has the power to make life better for people who constantly deal with pain by creating treatment plans just for them, thanks to predictive analytics. With the help of analyzing big amounts of data and what patients share about their experiences, AI systems can spot trends and suggest specific ways to manage pain more successfully.

What are the limitations of AI in chronic pain management?

When it comes to managing chronic pain with AI systems, there are a few hurdles we can’t ignore. For starters, chronic pain is complex and how people feel pain varies from one person to another. This makes it tough for AI algorithms to always get it right when figuring out how much pain someone is in or the specific details of what they’re going through. On top of that, there are ethical issues we need to think about. These include making sure the AI doesn’t have any built-in biases and ensuring patients know what’s happening every step of the way (that’s informed consent). Another big deal is keeping patient information private since these ai systems need access to personal health data.

Key Highlights

  • In the healthcare world, artificial intelligence (AI) is making big changes, especially when it comes to managing long-term pain.
  • With AI tools like predictive diagnostics, natural language processing, and robotics, doctors are getting better at figuring out how to deal with pain.
  • Thanks to AI, there’s a chance for more accurate diagnoses. It also helps in keeping patients involved and tailoring treatments just for them.
  • There have been real examples where AI made things better in targeted medicine and even using virtual reality to help control pain.
  • By bringing AI into health tech more broadly. we’re looking at a future where dealing with chronic pain could get a lot easier.

Increasing Patient Retention and Revenue with Referral Management

The ratio between the number of dentists and the population in the USA is 61:100000. More than one in five (21.3%) said that they had not visited the dentist in the last few years. One of the top reasons adults cite for avoiding the dentist is the inability to find a convenient location or appointment time. Specifically, 19% of adults had not visited the dentist in a few years because they cannot find a convenient location or appointment time. As a dentist or dental practice manager, it is crucial to not just manage existing patients but to account for lost opportunity and plan to improve patient experience, especially with appointment schedule and completion. This will result in an increase in the number of patients visiting dental centers. 

Dental centers/groups can begin by leveraging technology to manage the patient referral workflow. Inbound patient referrals having dental issues usually have accompanying ailments such as diabetes or accidental injuries. A seamless experience from appointment scheduling to treatment completion will positively impact patient satisfaction and the volume of inbound patient referrals.

Existing Patient Referral Management Workflow in a Dental Center

Did you know? In a year, 15 billion faxes are sent out with patient referral information in the USA. Practices receive referrals through fax, online forms, direct messaging, email, virtual print, direct walk-ins, and other channels. A typical dental center or dental group is a high inbound referral setup. Dental centers receive large volumes of referrals weekly (ranging from 50 per week to even several hundred per week) depending on the number of patients visiting the center and the number of clinics sending referrals to them. An effective referral management solution will help manage small or big volumes of referrals by reducing manual tasks and using automation and structure where possible.

How to increase Revenue with Referral Management

Dental centers usually have a dedicated team of referral coordinators who receive, accept, and process the referral requests. These referral coordinators manually key in the necessary details into an EMR/ EHR system and create a referral. The time spent by a referral coordinator in a completely manual process can be reduced by using technology. Productivity and efficiency are increased by introducing technology to aid the process. It results in piling up requests that are not yet processed. When the referral coordinator does not have the required information to process the referral, he has to contact the referring provider. This further incurs time and results in a slow referral processing rate. This, in turn, has a negative impact on patient experience. Hence, patient referral leakage also becomes imminent.

Consequences of a Slow Referral Network

  1. Revenue loss is a direct result of the untimely processing of referrals
  2. Providers stop referring to the center thereby harming its reputation
  3. Waiting times and appointment scheduling process affects patients requiring critical and          immediate attention

Challenges Faced by a Dental Center

  1. Multiple Referral Channels: For the specialist/imaging center that receives referrals, face more difficulties than the referring provider. They receive referrals through various channels like fax, email, direct message, website, user-filled forms, etc. Managing and tracking all of it manually is a tedious task. The chances of missing out on a referral are high.
  2. Appointment Scheduling and Patient No-Show Rates: After receiving the referral, the specialist/imaging center schedules appointments with the patient. In some cases, the patients are not notified clearly about the appointment. When patients do not show up, it is difficult for the specialist/imaging center to track. It results in revenue loss and patient dissatisfaction.

Let us review a typical referral process to elaborate on the challenges faced by the dental centers.

  1. Patient Visits the PCP

Andrews met with an accident recently. He met his PCP, Dr. John, immediately as he was experiencing pain in his jaw. After examining him, Dr. John wanted him to consult a dentist. The doctor then initiated the referral.

  1. PCP Initiates the Referral

John created a referral in his EMR. He did not have time to do the insurance pre-authorization so he left it to Andrews. He then found a dentist and gave him referral information verbally. Now when he met the specialist, Andrews had to again elaborate on his condition and problems to him. This is time-consuming for the specialist as he wastes time on the same information twice.

  1. Specialist Requires More Information

The specialist, Dr. James, is a famous dentist in the locality. After receiving the referral, he schedules an appointment with Andrews. After the appointment, Dr. James wants more information about the patient’s history and diagnostic reports. Now, he has to wait for the PCP, Dr. John, to send him the relevant information.

  1. No Tracking System for Referrals

As Dr. James is a famous dentist in the locality, he receives numerous referrals in a day. There is no tracking system for him to know how many referrals he received, how many were processed, in what status each referral is in, etc. So it is difficult for Dr. James to understand the analytics of his specialty.

Overcome your challenges with HealthViewX Patient Referral Management Solution:

With a Referral Management solution like HealthViewX, you can eliminate all your challenges and achieve referral loop closures in an efficient way. Here are some of the key features that will help you transform your referral process:

  1. Multi-Channel Referral Consolidation

The HealthViewX solution can capture fax, phone, email, online form referrals or any other referrals in a single interface. It makes it easy to monitor and manage all channels of referrals in a single queue.

  1. Patient Coordination Framework

After finding the receiving provider, the referral coordinator refers the patient. When the receiving provider receives the referral, the provider will get notified of the referral. Even the patient will be notified of the referral. The receiving provider can schedule appointments based on the patient’s comfort. This will cut down patient no-show rates.

  1. Referral Tracking

HealthViewX gives a clear picture of how a referral has progressed with the help of a timeline view. Every referral has a status that conveys in which stage the referral is in. With the help of a customizable dashboard, the exact number of referrals waiting to be processed can be identified easily.

  1. New Referral Channel

HealthViewX Referral Management solution supports a new channel for sending and receiving referrals. This is called the desktop application. Sources like email, website, direct message, fax, etc are not secure and difficult to handle. On the other hand, desktop applications are a secure source for sending and receiving referrals. Also, documents can be attached and sent as a referral.

  1. Referral Data Consolidation

It has options for printing the consolidated data about the referrals and the referral history of any patient as a hard copy at any time in pdf/excel.

  1. Secure Data Management

HealthViewX Patient Referral Management is HIPAA compliant. It manages all patient-related documents securely.

  1. Referral Analytics

Helps in tracking the number of referrals and gives complete information about the referrals processed, missed, scheduled, etc. with the help of a Referral Data-centric Dashboard.

Talk to us to understand how to streamline and automate the end-to-end referral cycle without disturbing your existing EMR setup.

2021 CPT Codes by the CMS for Medicare Extension Care Management Programs

Chronic Care Management:

The chronic care management program was virtually untouched by the 2021 Final Rule from CMS. There are three main CPT codes and two add-on CPT codes in 2021 that may be billed by primary care providers for CCM services.

C

Requirements for CCM:

Non-Complex CCM:

  • Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
  • Patient consent (verbal or signed)
  • Personalized care plan in a certified EHR and a copy provided to the patient
  • 24/7 patient access to a member of the care team for urgent needs
  • Enhanced non-face-to-face communication between patient and care team
  • Management of care transitions
  • At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by a physician or other qualified healthcare professional
  • CCM services provided by a physician or other qualified healthcare professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management activities

Complex CCM:

Shares common required service elements with CCM but has different requirements for:

  • Amount of clinical staff service time provided (at least 60 minutes)
  • The complexity of medical decision-making involved (moderate to high complexity)

CPT Reimbursement Codes for CCM Service:

Non-complex CCM:

  • CPT Code 99490– This code requires that patients must have two or more chronic conditions, as well as documented consent to enroll in the program AND receive at least 20 minutes of CCM services from clinical staff within a given month. A personalized care plan, which shows an assessment of all patient factors and identifies gaps and barriers to be addressed, is also required. Reimbursement Rates – CPT Code 99490 – $42/patient/month.
  • CPT Code 99439 (formerly  G2058) -This code allows providers to bill for each additional 20 minutes spent for Basic CCM services in a given month, up to 2 times. For example, if CCM services were provided for at least 40 minutes with a patient in a given month that was not Complex, 99490 ($42) and 99439 ($38) would be billed together for that month. Reimbursement Rates – CPT Code 99439 (formerly  G2058) – $38/patient/month.

Complex CCM:

  • CPT code 99487– This code has a higher rate of reimbursement than the Basic CCM CPT code. To bill using this code requires moderate or high complexity in medical decision making AND acknowledgment by both patient & provider of an acute exacerbation (generally defined as a sudden worsening of a patient’s condition that necessitates additional time and resources). The patient must receive at least 60 minutes of services from clinical staff within a given month to bill for this code. Reimbursement Rates – CPT Code 99487 – $93/patient/month.
  • CPT code 99489 – The same as with the Basic Chronic Care Management code, the Complex Chronic Care Management code also has an add-on CPT code to cover time spent beyond 60 minutes. It allows for billing for each additional 30 minutes spent for Complex CCM services within a given month. Reimbursement Rates – CPT Code 99489 – $45/patient/month.

Transitional Care Management:

Transitional Care Management (TCM) services address the hand-off period between the inpatient and community settings. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

medicare reimbursement codes

Requirements for TCM:

  • Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via the telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
  • Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision-making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
  • Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
  • Obtain and review discharge information.
  • Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments.
  • Educate the beneficiary, family member, caregiver, and/or guardian.
  • Establish or reestablish referrals with community providers and services, if necessary.
  • Assist in scheduling follow-up visits with providers and services, if necessary.

CPT Reimbursement Codes for TCM Service:

  • CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge. Reimbursement  rate – $175.76/patient/month.
  • CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge. Reimbursement  rate – $237.11/patient/month.

Allowed reported services alongside TCM services include,

  • Prolonged services without direct patient contact (99358-99359);
  • Home and outpatient international normalized ratio (INR) monitoring (93792-93793);
  • End-stage renal disease (ESRD) services for patients ages 20 years and older (90960-90962, 90966, or 90970);
  • Interpretation of physiological data (99091); and
  • Care plan oversight (G0181-G0182).

Remote Patient Monitoring:

RPM involves the collection and analysis of patient physiologic data that are used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition.

CMS

Requirements for RPM:

To qualify for CMS reimbursements for utilizing the RPM services efficiently, the service providers and hospitals need to ensure the following:

  • Medicare part B patients are imposed 20% of copayment (renouncing the copayments regularly can trigger penalties under the Federal Civil Monetary Penalties Law and also the Anti-Kickback Statute)
  • Patients must take the remote monitoring services and are required to monitor for a minimum of 16 days to be applicable for a billing period.
  • The RPM services must be ordered by skilled physicians or other qualified healthcare experts.
  • Data must be wirelessly synced for proper evaluation, analysis, and treatment.

CPT Reimbursement Codes for RPM Service:

  • CPT code 99453 – It is a one-time practice expense reimbursing for the setup and patient education on RPM equipment. This code covers the initial setup of devices, training and education on the use of monitoring equipment, and any services needed to enroll the patient on-site. Reimbursement  rate – $18.77/patient/month.
  • CPT code 99454 – This code covers the supply and provisioning of devices used for RPM programs, and the code is billable only once in a 30-day billing period. Reimbursement  rate – $64.44/patient/month.
  • CPT code 99457 – This code covers the direct monthly expense for the remote monitoring of physiologic data as part of the patient’s treatment management services. To receive reimbursement, the physician, QHP or other clinical staff must provide RPM treatment management services for at least 20 minutes per month. Reimbursement  rate – $51.61 (non-facility); $32.84 (facility) /patient/month.
  • CPT code 99458 – This code is an add-on code for CPT Code 99457 and cannot be billed as a standalone code. This code can be utilized for each additional 20 minutes of remote monitoring and treatment management services provided. Reimbursement  rate – $42.22 (non-facility); $32.84 (facility) /patient/month.

Principal Care Management:

PCM codes are intended to cover services for patients with only one complex chronic condition that requires management by a specialist. Like other chronic care management (CCM) codes (chronic care management, transitional care management), the PCM codes are intended to reimburse physicians for the additional work they do to take care of high-risk, complex patients. This includes the extra time and work required for medication adjustments, creating a care plan, patient follow-up, and more.

Healthcare technology

Requirements for PCM:

  • One complex chronic condition lasting at least 3 months, which is the focus of the care plan,
  • The condition is of sufficient severity to place the patient at risk of hospitalization or has been the cause of recent hospitalization,
  • The condition requires development or revision of a disease-specific care plan,
  • The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities

CPT Reimbursement Codes for PCM Service:

  • CPT Code G2064 – requires 30 minutes of provider (allergist, NP, PA) time each calendar month to care for the patient. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $52/patient/month.
  • CPT Code G2065 –  requires 30 minutes of clinical staff time directed by a provider each calendar month for patient care. Provider supervision does not require the provider to be onsite while clinical staff performs PCM services. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $22/patient/month.

Annual Wellness Visit:

The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical.

healthcare solutions

Requirements for AWV:

For G0438 (initial visit),

  • Billable for the first AWV only.
    • Patients are eligible after the first 12 months of Medicare coverage.
    • For services within the first 12 months, conduct the Initial Preventive Physical Exam (IPPE), also referred to as the Welcome to Medicare Visit (G0402).
  • The patient must not have received an IPPE within the past 12 months.
  • Administer a Health Risk Assessment (HRA) that includes, at a minimum: demographic data, self-assessment of health status, psychosocial and behavioral risks, and activities of daily living (ADLs), instrumental ADLs including but not limited to shopping, housekeeping, managing own medications, and handling finances.
  • Establish the patient’s medical and family history.
  • Establish a list of current physicians and providers that are regularly involved in the medical care of the patient.
  • Obtain blood pressure, height, weight, body mass index or waist circumference, and other measurements, as deemed appropriate.
  • Assess a patient’s cognitive function.
  • Review risk factors for depression, including current or past experiences with depression or mood disorders.
  • Review patient’s functional ability and safety based on direct observation, or the use of appropriate screening questions.
  • Establish a written screening schedule for the individual, such as a checklist for the next 5 to 10 years based on appropriate recommendations.
  • Establish a list of risk factors and conditions for primary, secondary, or tertiary intervention.
  • Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
  • At the patient’s discretion, furnish advance care planning services.

For G0439 (subsequent visit),

  • Billable for subsequent AWV.
  • The patient cannot have had a prior AWV in the past 12 months.
  • Update the HRA.
  • Update the patient’s medical and family history.
  • Update the current physicians and providers that are regularly involved in providing the medical care to the patient, as developed during the initial AWV.
  • Obtain blood pressure, weight (or waist circumference, if appropriate), and other measurements, as deemed appropriate.
  • Assess a patient’s cognitive function.
  • Update the written screening schedule checklist established in the initial AWV.
  • Update the list of risk factors and conditions for which primary, secondary, and tertiary interventions are recommended or underway.
  • Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
  • At the patient’s discretion, the subsequent AWV may also include advance care planning services.

CPT Reimbursement Codes for AWV Service:

The four CPT codes used to report AWV services are,

  • G0402 Initial Preventive Physical Exam – This code is used for patients visiting within 12 months after enrolling in Medicare.
  • G0438 Initial Visit – This visit is eligible within 11 calendar months from the date of IPPE.
  • G0439 Subsequent Visit – This code is used for every subsequent visit. Patients are eligible for this benefit every year after their Initial AWV.
  • CPT 99497/99498 – Patients are eligible for an Advance Care Planning (ACP) at any time. But if performed during an AWV, the patient has no copay.

Behavioral Health Integration:

Integrating behavioral health care with primary care (“behavioral health integration” or “BHI”) is an effective strategy for improving outcomes for millions of Americans with behavioral health conditions. Medicare makes separate payments to physicians and non-physician practitioners for BHI services they furnish to beneficiaries over a calendar month service period.

medicare cpt codes

Requirements for BHI:

  •  Any mental or behavioral health condition being treated by the billing practitioner, including substance use disorders, that, in the clinical judgment of the billing practitioner, warrants BHI services.
  • The diagnosis or diagnoses could be either pre-existing or made by the billing practitioner and may be refined over time.

CPT Reimbursement Codes for BHI Service:

The CPT code used to report BHI services is,

  • CPT Code 99494 – Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional.

References:

https://signallamphealth.com/2021-medicare-cms-chronic-care-management-ccm-cpt-code-updates/

https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1

https://college.acaai.org/new-principal-care-management-cpt-codes/#:~:text=G2064%20requires%2030%20minutes%20of,is%20%2452%2Fpatient%2Fmonth

https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/transitional-care-management.htm

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/BehavioralHealthIntegration.pdf