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Why Interoperability is Crucial in Healthcare Operations

Data interoperability in healthcare refers to the seamless and secure exchange of patient information among different healthcare systems, providers, and organizations. The lack of interoperability can lead to fragmented data silos, making it difficult for healthcare professionals to access comprehensive patient information. This can result in inefficiencies, medical errors, and ultimately hinder the delivery of quality care. In this article, we’ll delve into the significance of interoperability in healthcare and explore how it can streamline processes, improve patient care, and drive innovation in the industry.

According to research posted by the Office of the National Coordinator for Health Information Technology concerning non-federal acute care hospitals in the U.S.:

Only 46% of hospitals had required patient information from outside providers or sources available electronically at the point of care.
55% of hospitals named their exchange partners’ EHR systems’ lack of ability to receive data as a barrier to interoperability.
Only 38% of hospitals had the ability to use or integrate healthcare data from outside sources into their own EHRs without manual entry.

What is Interoperability in Healthcare?

Interoperability in healthcare refers to the ability of different healthcare information systems, devices, and software applications to seamlessly exchange and use patient data. This data can encompass a wide range of information, from electronic health records (EHRs) and diagnostic results to medication lists and treatment plans.

Interoperability ensures that healthcare providers, including hospitals, clinics, and physicians, can access and share patient data efficiently, securely, and in a format that is understandable by all systems involved. This capability allows for improved communication and coordination among healthcare providers, leading to better patient care.

The Importance of Interoperability in Healthcare

Enhanced Patient Care

At the heart of healthcare operations lies patient care. Interoperability directly impacts the quality and efficiency of patient care by enabling healthcare providers to access comprehensive and up-to-date patient information. When a physician has access to a patient’s complete medical history, including previous diagnoses, allergies, and medications, they can make more informed decisions about treatment options, ultimately leading to better outcomes.

Reduced Errors

One of the most significant benefits of interoperability is the reduction in medical errors. With seamless data sharing, healthcare providers can avoid duplication of tests and procedures, ensuring that patients receive the right care at the right time. Moreover, accurate and complete patient records reduce the risk of medication errors, allergic reactions, and other potential harm to patients.

Improved Efficiency

Interoperability streamlines administrative processes in healthcare. Tasks that once required manual data entry and paperwork, such as referrals, authorizations, and billing, can now be automated through interoperable systems. This not only reduces administrative burden but also accelerates the overall healthcare process, allowing providers to focus more on patient care.

Cost Savings

By eliminating redundant tests and procedures, reducing administrative overhead, and preventing errors, interoperability can lead to significant cost savings in healthcare. It helps lower healthcare costs for both providers and patients, making healthcare more accessible and affordable.

Facilitating Research and Innovation

Interoperability is the backbone of healthcare research and innovation. When researchers and healthcare organizations can access a vast pool of anonymized patient data, they can identify trends, study disease patterns, and develop new treatments more effectively. This has the potential to drive groundbreaking discoveries and advancements in healthcare.

Challenges and Barriers to Interoperability

While the benefits of interoperability in healthcare are clear, achieving seamless data exchange is not without its challenges. Several barriers hinder its widespread adoption:

Technical Heterogeneity: Healthcare systems use a variety of different technologies and standards for data storage and transmission. Achieving interoperability often requires bridging the gap between these disparate systems.

Privacy and Security Concerns: The sensitive nature of patient data raises concerns about privacy and security. Healthcare organizations must implement robust security measures and comply with regulations like HIPAA (Health Insurance Portability and Accountability Act) to protect patient information.

Resistance to Change: Implementing interoperable systems requires a change in processes and workflows, which can face resistance from healthcare providers and organizations accustomed to traditional practices.

Funding and Investment: The initial investment required to implement interoperable systems can be significant. Smaller healthcare providers may struggle to allocate the necessary resources.

Regulatory and Legal Challenges: Compliance with various state and federal regulations can be complex and time-consuming. Healthcare organizations must navigate a complex regulatory landscape to ensure data sharing is done legally and ethically.

In a 2018 survey of U.S. health system executives and finance leaders, “52% said that data sharing is the technology that will have the biggest positive impact on the patient experience.”

Future Trends and Solutions

Despite the challenges, the push for interoperability in healthcare continues to gain momentum. Several trends and solutions are emerging to address these challenges and drive the adoption of interoperable systems:

Standardization: The development and adoption of standardized data formats and protocols, such as Fast Healthcare Interoperability Resources (FHIR), are simplifying data exchange between systems.

Data Exchange Networks: Health information exchanges (HIEs) and regional data exchange networks can facilitate data sharing among healthcare organizations within a defined geographic area.

Patient Empowerment: Patients are gaining more control over their health data through patient portals and mobile apps, allowing them to share their information with different healthcare providers.

Cloud-Based Solutions: Cloud computing offers scalable and cost-effective solutions for healthcare data storage and exchange, making interoperability more accessible to smaller providers.

HealthViewX: The Solution to Data Interoperability

The HealthViewX platform is emerging as a powerful solution to overcome the data interoperability challenge in healthcare operations. HealthViewX’s proprietary Interoperability Engine, HealthBridge, is designed to bridge the data interoperability gap and streamline healthcare operations. HealthBridge enables end-to-end care orchestration with bi-directional health information system integrations such as EMR/EHRs, HMS, PHMS, LIS, etc. HealthBridge has the ability to communicate the data between multiple health systems seamlessly and it supports API, HL7 v2, JSON, XML, FHIR (DSTU2 and R4), and custom integrations (DB, File-based) format. Here’s how it overcomes the challenges:

Aggregation of Data: HealthViewX can aggregate data from various sources, including EHRs, labs, and other healthcare systems, into a unified and standardized format.

Secure Data Exchange: The platform ensures robust security and compliance with regulations like HIPAA to protect patient data during exchange.

Standardization: HealthViewX employs standardized data formats, such as Fast Healthcare Interoperability Resources (FHIR), to facilitate seamless data exchange.

Compliance Management: The platform simplifies compliance management by automating the process of adhering to healthcare regulations, reducing the administrative burden.

Integration of Legacy Systems: HealthViewX is compatible with legacy systems and can bridge the technological gap, making it accessible to healthcare organizations with older infrastructure.

Benefits of HealthViewX in Healthcare Operations:

The HealthViewX platform brings about a range of benefits that transform healthcare operations,

Efficiency: By aggregating data and simplifying data exchange, HealthViewX reduces administrative overhead, streamlines workflows, and enhances overall operational efficiency.

Enhanced Patient Care: Healthcare providers can access comprehensive and up-to-date patient information, improving decision-making and ultimately delivering better patient care.

Reduced Errors: The platform reduces the risk of medical errors by ensuring accurate and complete patient records, ultimately enhancing patient safety.

Cost Savings: With efficient data sharing and reduced administrative costs, healthcare organizations can achieve significant cost savings.

Innovation: HealthViewX’s data exchange capabilities facilitate research and innovation by providing access to a wealth of anonymized patient data, enabling groundbreaking discoveries in healthcare.

Improved Patient Experience: Patients benefit from faster and more efficient healthcare services, with the ability to share their data easily with various healthcare providers.

Blockchain Technology: Blockchain is being explored as a secure and transparent way to store and exchange healthcare data, addressing privacy and security concerns.

Conclusion

Interoperability is not just a technical requirement in healthcare; it’s a critical component that can transform the way healthcare is delivered. The achievement of data interoperability is paramount to delivering high-quality care, reducing errors, and enhancing efficiency. While challenges remain, ongoing efforts to standardize data formats, address privacy concerns, and empower patients are driving the healthcare industry closer to a future where seamless data exchange is the norm.

HealthViewX emerges as a comprehensive solution to the data interoperability challenge, enabling healthcare organizations to overcome the hurdles and revolutionize healthcare operations. By aggregating data, ensuring secure data exchange, and simplifying compliance management, HealthViewX is not just a platform but a catalyst for positive change in healthcare. It empowers healthcare providers to deliver the best possible care and ensures that patients receive the attention and treatment they deserve, ultimately leading to a healthier and more connected healthcare ecosystem. As healthcare providers and organizations continue to embrace interoperability, patients will benefit from safer, more efficient, and more cost-effective healthcare services.

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 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.

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

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.

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.

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.

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.

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.

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.

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

The Importance of Clinical Call Center Nurses in the RPM Care Journey

The emergence of Remote Physiological Monitoring (RPM) has greatly contributed to the rapid adoption of virtual health services. This practice would not be possible without the work of clinical call center nurses, who observe the condition of patients and accordingly make relevant health decisions.

How does RPM work?

RPM uses technology to track a patient’s vital parameters such as heart rate, blood pressure, weight, etc. This data is recorded by the device and sent to health professionals involved with the patient’s care. The care provider can then make informed decisions on the patient’s health. RPM devices notify the care provider if any abnormal vitals are detected. They also allow patients to receive quality health care from a virtual setting. Effective RPM systems result in higher patient satisfaction while increasing the revenue of care providers.

The role of Call Centers in RPM

Clinical Call Centers play a crucial role in the RPM care journey. RPM devices track a large number of complex metrics relating to the patient’s health. Any data recorded by an RPM device is useless until a qualified health professional is able to analyze it. This is where call center nurses factor into the Care Journey. The RPM device emits data through the provider’s RPM software to the clinical center. Here the data can be received and analyzed by the nurses in charge of the virtual patient care. They can record a patient’s progress and better understand how a patient responds to treatment. If there are any slight deviations from the care plan, nurses can video conference with the patient to identify and address the source of the irregularity. If there are any concerning metrics, the nurses can immediately connect the patient with the necessary professional.

How RPM help Call Center Nurses

Call Center Nurses may be in charge of monitoring hundreds of patients in a virtual manner. Without a Remote Monitoring option, nurses need to manually contact individual patients. RPM devices can connect with these patients on a daily basis, without constant human interaction. These devices can collect the data of hundreds of patients and send these results to the call center in just a few minutes. RPM also allows patients to track their health from the comfort of their homes-meaning providers are able to turn their attention to their most at-need patients.

RPM and the COVID-19 Pandemic

The COVID-19 pandemic has heightened the importance of virtual care services like RPM. The pandemic has greatly decreased the healthcare industry’s focus on combating non-COVID related ailments. However, providers with existing RPM mechanisms are benefiting from the ability to monitor health through a virtual platform. In addition, patients who suffer from chronic conditions are still able to receive daily updates on their health.

Characteristics of a functional RPM platform

The following characteristics can be found among all effective RPM systems:

Reduce Emergency Situations: RPM devices can track any abnormal patterns and immediately report them to a health center. Emergency situations are of increased danger to the health of chronic care patients. RPM devices can provide a timely intervention and allow the patient to receive care before an emergency situation unfolds.
Reduce Readmissions: An efficient RPM platform can prevent patients from being readmitted for their existing conditions. By tracking the trajectory of the patient’s health, nurses can notify patients when they deviate from their care plan. This helps patients stay on top of their treatment while decreasing the probability that they are readmitted.
Increased Patient Involvement: The interactive nature of RPM gives patients the opportunity to be more involved in their care. This means patients are more informed on their condition and the treatment plan referred to them. Ultimately a more involved patient increases the likelihood of recovery.

The increased importance of virtual care has allowed RPM to emerge as a powerful tool in care delivery. The proper use of these technologies greatly enhances the convenience and effectiveness of health care.

Schedule a demo and learn how HealthViewX is transforming the Care Journey for both patients and providers!

How Early Adopters of Healthcare Technologies Are Benefited

Today, healthcare technology has extensively transformed the healthcare sector by changing the lives of many people and also changing the way the healthcare industry operates. It is driving healthcare more than any other force and has resulted in meaningful growth for the future. It has helped the industry by bridging the communication gap between patients and providers.

Though American healthcare providers have embraced the use of EHRs at record-high rates, they lag behind the rest of the world in adopting other digital health technologies such as telehealth, artificial intelligence, etc.

Early Adopters of Healthcare Technology Are Benefitted

There is no denying that the early adopters of healthcare technology are benefitting the most. It is extremely advantageous to providers and has played a pivotal role in bringing noticeable changes to the healthcare industry. There are providers skeptical about the implementation cost and the medical value of technological advances.

Though there remains skepticism among providers about healthcare IT, this situation is likely to change among the U.S. medical providers. Efforts are underway to increase the adoption of healthcare IT and spur innovative solutions. The early adopters are witnessing optimistic results like the ability to provide better care, the reduction of administrative costs, and the power to provide value-based care for their patients.

Some of the benefits are

The adopters are benefitting from the increased revenue government reimbursements for Medicare patients. This allows them to optimize their potential revenue and provide value-based care for their patients.

The adopters have been able to retain and expand their patients through a well-connected care system.

Healthcare IT lets patients have access to their health records, allowing them to take part in their care programs or plans.

With the help of electronic health records, patients have been more engaged in their health and have greater satisfaction with care.

The providers have been able to retain and expand their patient base with value-based care and better results.

Health IT provides 360-degree care which enables both the patients and providers to have a better understanding of the patient’s current health condition and unique healthcare needs thus enabling the physician to come up with individual care plans.

Eventually the adoption of health IT will bring great changes in the healthcare system benefitting both the providers and the patients.

Early adopters, in general, are experiencing the following benefits as well:

Connected health helps patients to self-manage their health thus supporting the physicians for a better health outcome.
Providers are able to retain and expand their patient base while focusing on value-based care
Providers are able to bring in additional revenue by increasing their patient base and aligning with their business strategy.
Early adopters are maximizing their profit through increased revenue government reimbursements for Medicare patients.
Adopting health IT reduces the cost of care for their patients.
The technology behind health IT is advancing rapidly and is transforming the way the industry operates.
Healthcare IT enables the secure exchange of sensitive patient data.
Health care IT has helped to build better patient-provider relationships.
Detailed care - Provides physicians more face time, improved outcomes, focus on preventive measures, reduced readmissions, and reduces paperwork.
Patients will experience higher satisfaction, increased confidence, and enhanced treatment adherence.
Enables better care quality and patient-centered care.

In Conclusion, health IT can tackle the increasing demands on healthcare. It is especially advantageous for the industry considering the increase in chronic diseases and people with multiple conditions. Healthcare technology has the potential to improve the overall outcome by reducing healthcare costs and increasing access to care.

Talk to HealthViewX Solution experts to understand more about their HOPE Platform and solutions like Referral Management, Chronic Care Management, Telehealth Solutions, Remote Patient Monitoring, and many more. Schedule a demo today!

Revenue lost due to patient leakage in hospitals and health systems

The last few years have been a tumultuous time for hospitals and health systems due to the high patient leakage rate. Even today, patient leakage is a key concern and remains an unsolved challenge in many of the health systems. Health systems are losing more than 20% revenue due to inefficient organizational referral processes, as a result, patients are opting to different care providers for their care needs. Identifying the gaps or latitude to go out of the system, and sealing this, is the basic step that health systems need to take in solving patient leakage challenge.

What are the main causes of patient leakage?

Here are some reasons why patient leakage happens

– Referring physicians refer patients to out-of-network providers

– Patients move out of the care network due to poor care coordination

– Unavailability of a specialist within the care network

Patient Leakage and its consequences

Though in most hospitals patient leakage is contributing to significant revenue loss, this loss is ignored, and not given much importance. Health systems and hospitals need to consider this leakage extremely important. Non-coordinated or fragmented care is one of the main reasons for patient leakage. The point is to emphasize on some damaging consequences patient leakage can bring on care quality and patient health outcomes.

Understanding the actual causes of this leakage and taking tangible steps to address this challenge is vital. It is the responsibility of the health system to track and manage patient referrals in a better way with a solution for tracking leakages and referrals. Otherwise, it can damage the health system’s reputation, undermine its brand value, and even jeopardize its competitive edge.

Challenges in processes that cause patient leakage

Streamlining different processes for different aspects is required for better overall operational efficiency. One such process that needs attention to arrest leakage is the patient referral process. Health systems need to adapt to solutions that will help seal this leakage. HealthViewX helps referral coordinators in health systems to manage patient referral efficiently and improve care, performance, compliance, and reduce leakage.

The current referral process lacks certain mechanisms to make this process effective. Hospitals and health systems need a referral solution in addition to an EMR to solve their referral challenges especially referral leakage.

An ideal referral solution for hospitals should have the following features

Multi-channel referral consolidation

Health systems have multiple access points for patients and chances are that health systems may miss following-up with some referrals. The solution needs to consolidate referrals from multiple sources like fax, email, phone calls, online forms, etc. It should integrate well to bring all of these referrals into one single queue and ensure not a single referral is missed.

Secure exchange of information

A HIPAA compliant solution that supports the secure exchange of sensitive patient information among the care providers involved in patient care is a must. The provider should be able to attach documents securely at any time for one another’s reference.

Patient referral history

Both the referring physician and the receiving provider should have access to the entire referral history. All required information right from the time a referral is initiated and consequent diagnosis reports, referral status, etc. should be available at any point of care.

Scheduler Integration

Patient convenience is one of the most important factors in providing care. Scheduling appointments as per patient convenience and automated reminders for both patient and provider about the appointment is mandatory.

Dashboard and referral insights

The solution has to give complete data of the referrals flowing into the health system. The number of referrals processed, number missed and many more as per the requirement of the health system. These data analytics should give the practice a clear picture of how referrals are handled and where the leakage is happening.

Speak to HealthViewX solution experts to understand more about HealthViewX Referral Solution features that will help solve some of the challenges in the patient referral process and increase revenue through effective tracking. Schedule a demo today!