Episode Overview
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Daniel Marino:
Welcome to value-based care insights. I am your host, Daniel Marino. As we now move into 2025, I'm sure many of you realize that we have a new fee schedule from Medicare. Our friends at Medicare released the new final rule last November, November first to be exact. And there are some pretty significant changes that we really need to consider as we're now moving into to 2025. And some of those changes as I kind of dove into it a little bit we're really focused on some new codes, some strategies to make more equitable reimbursement for the different physicians, medical groups, and so forth, around quality, around innovation, around managing what's occurring with some of our Medicare beneficiaries. And when I looked at it, there were 4 key areas that really resonated with me. And again, our background, and my background in particular, is really supporting a lot of the medical groups and the physician practices as well as the hospitals that have many employed physicians. So those 4 areas are really start with really the payment impact. So there is a pretty significant impact to providers, to how we're going to code with the new fee schedule. Second is, there's numerous new and expanded services, new codes, new ways to begin to get reimbursed for the services that are being provided. The 3rd area is around surgery and no secret, there's a big incentive to shift from acute to ambulatory, there's a new series of codes that are being proposed and included and build and allow for some reimbursement that really provider organizations need to be aware of. And then, lastly there's a major impact on rural health clinics and federally qualified healthcare centers. And as we think about the coding, these organizations, in particular, have a real opportunity to improve some of their coding, improve their billing, improve some of their collections.
Well, I'm excited today to have 2 of my colleagues. They've been on the show before, extremely knowledgeable in this area. Lucy Zielinski. She's a certified coder managing partner with Lumina health partners, and Sarah Hartley, former executive of a large health system in the Chicago area, and is a true expert in coding and clinical documentation improvement ladies welcome to the program.
Lucy Zielinski:
Thanks Dan.
Daniel Marino:
So, Lucy, let's start with you. Maybe you just give a quick, you know, couple a minute or 2 summary. What are some of the big changes that you're seeing with this new rule as we move into 2025?
Lucy Zielinski:
Well, 1 clearly rule that changes every year is kind of that conversion factor, the impact on payments. Right? This is a general thing, as we all know, there's this thing called budget neutrality, and they've been kind of poking away at the conversion factor. So this year 2025, we are going to be seeing a decrease of 94 cents of the conversion factor compared to 2024, and this amounts to almost 3% of total dollars or revenue. So that's a big chunk.
Daniel Marino:
It is a big chunk, and I'll tell you. It's amazing that when I saw this, this is one of the things that really surprised me, and I know there was a this was pretty controversial, so I know folks like MGMA and HFMA, and so forth, pushed back on it. But as inflation has increased and costs have increased, you would think that the payment and the revenue would increase, but it actually has gone down almost 3%.
Lucy Zielinski:
Well, and it's gone down fee for service, as you know. But what we're seeing is an increase on the value-based care side. You mentioned that earlier, Dan. And there's also some changes with the HCCs, hierarchical condition categories. We are moving versions this year, and, as you know, HCCs impact many of the quality programs, including MIPS, MSSP, the ACOs and Medicare advantage plans. So providers really need to be aware of that impact as well.
Daniel Marino:
Yeah, it's interesting and good observation. I'll tell you, there's definitely an incentive that's out there, moving from fee for service to value-based care, and around some of these programs. So, Sarah, let me kind of dive into this with you when you look at the new rule and the new codes, what are the newer expanding services that you see that are included in this new rule that maybe our provider colleagues need to pay attention to?
Sarah Hartley:
Yeah. So some new coding and payment for caregiver training for providing direct caregiver services and supports some expansion. On our G 2211 codes, Medicare will pay when this code is added to the annual wellness visit or the vaccine administration, any Medicare part B preventative services they'll pay for this additional code, when you append the modifier.
Daniel Marino:
So let's dive into that a little bit, because I think this is an important point. So when providers are billing the annual wellness visit. You're saying now that, based on the risk or the complexity of the patient, they could also now, Bill, the G Code G 2211 code with that?
Sarah Hartley:
That's correct. So if they are treating a patient that has a complex condition, and they are continuing a relationship with that patient for this serious, complex condition over an extended period of time. They can bill for this code.
Daniel Marino:
Hmm, yeah, that's interesting. And what's the reimbursement? Or is there an RVU impact to it?
Sarah Hartley:
There is an RVU impact, Lucy.
Lucy Zielinski:
Yeah. So the reimbursement again depends on the state you're in and the local. However, it's around $16, and the RVU value is point 5. So physicians who whose compensation is based on RVUs, they're doing the work. They might as well capture this bill for it, and have that credit.
Daniel Marino:
Well, and I'll tell you again, another incentive to shift to value-based care right? Because annual wellness visits are a critical point or part of being able to identify all of the historical conditions of the patients as well as capturing HCCs. What about telehealth services? Telehealth has been, I think, for the most part, providers really like it. I think most patients really like it. There's a discussion as to whether telehealth is going to continue. It looks like heading into 2025. That's still going to remain an important part.
Sarah Hartley:
It is remaining an important part. And we've seen several services actually being added to telehealth for 2025, including caregiver training and some interactive telecommunication systems which now can include 2 way, real time audio only technology for the beneficiaries in their home.
Daniel Marino:
What about for behavioral health? I read an article that you know again, I think it was a study that came out. That said I think the article spoke to the fact that behavioral health performance and the output of behavioral health telehealth services was recognized and well received by patients even more so than some of the medical services. How does behavioral health telehealth fit into this.
Sarah Hartley:
They are allowing for 20 min increments around safety planning and they are also have some new codes for digital mental health treatment devices as well. So they are also recognizing the importance of telehealth in the behavioral health services.
Daniel Marino:
Yeah, I think that's a good one. I really do. You know, access and behavioral health is such a challenge, and many behavioral health providers have started to integrate telehealth services and just try to expand their provider resources and offering telehealth services, I think, is an excellent way of being able to provide those services. So I was really this was one of the things I was happy to see. Talk a little bit about some of the caregiver training. You mentioned it earlier. What's included in there? And then how do you know who's considered the caregiver? How do we bill for those?
Lucy Zielinski:
So Dan caregiver, caregiver training is being paid now. So these are new services, as you know, are being recognized for caregivers who are taking care of patients or their loved ones, and some of the topics that CMS is going to be reimbursing for our training for techniques. To prevent some of these conditions, like ulcers, wound care, infection, control as well as behavior, management and telehealth services will be paid as well. So any training via telehealth. They'll pay for those services now.
Daniel Marino:
They're going to actually combine and pay for both of those then, so they'll be as well as telehealth.
Lucy Zielinski:
Right training, via telehealth.
Daniel Marino:
Training via telehealth, which really makes sense. Well, if you're just tuning in, I'm Daniel Marino. You're listening to Value-based Care Insights. We're having a great discussion on the new 2025 CMS Medicare rules fee schedule rule that came out, and that we're all kind of working through as we enter into this New Year, and I'm here with Lucy Zielinski and Sarah Hartley. So one area that I or 2 areas I want to dive into a little bit further. One of them is dear and dear to my heart. It's really around care management, I've said for the longest time, and I think people have heard me say this, that care management is really the engine behind value-based care. Right? It's what drives a lot of the performance. But oftentimes it is really under reimbursed, and it's, I think, undervalued per se. How are what's changed, or what's enhanced with some of the new care management services? As we look at the new role?
Sarah Hartley:
This is really exciting, Dan. I agree. There's a new set of codes that we're seeing for advanced primary care management services that will support several existing care management and technology based services into a bundle of services that's then going to reflect those core elements when delivering that care.
Daniel Marino:
So is it. But what can you elaborate a little bit further? What needs to be documented, or does it look like, you know our providers doing this anyways, right now, or nurses doing this, anyways? Or how is this kind of linked into what the services that they're currently doing versus what some of the new services maybe they need to think about going forward.
Sarah Hartley:
So any physicians, nurse practitioners who are who use an advanced primary care model of care can bill for these services when they are the continued focal point for all of the health services. They have to be responsible for all primary care services for that beneficiary. So that means that their documentation has to support that documentation has to support the continuity of care. This really helps ensure that our patients have access to that high quality care in primary care services.
Daniel Marino:
Hmm, yeah.
Lucy Zielinski:
Yeah these codes are really replacing those chronic care management codes that physicians. Before, and they used to have to track time right? So you had to watch the clock, measure the time, notate the time, so there is no time threshold now, it's based on how many chronic conditions. So there's 3 levels now, and based on how many chronic conditions, there's a corresponding code.
Daniel Marino:
Yeah, that's interesting. And I'll tell you hopefully, a lot of the care managers are happy about this, because I'll tell you trying to keep a patient on the on the phone or talk with them. To hit that 20 min, mark to me, seemed like it was a little unfair. I think if you're managing the patient and the patient has 2 or even 3 chronic conditions, and you're doing your check-ins, you're evaluating the meds, you're only spending 10 or 15 min, not the full 20. You should be able to bill the higher code because you're still managing the conditions around the risk level.
Lucy Zielinski:
Yeah, Dan, so there's 3 levels of these codes now. And the 1st Level is for people with one chronic condition and the reimbursement there is 16, about $16 a month per member. And the Second Level G0557 is for persons with 2 or more chronic conditions. And the last one is G0558 is for qualified Medicare beneficiaries with 2 or more conditions, and that reimbursement is around a $112 per member per month. So that's quite a bit of money.
Daniel Marino:
It is, it is. And you know the big takeaway for me is this, you know, they're removing the time based factor on this, and you know, in working with many organizations on building their care management platform, so many care managers were so focused on hitting the time criteria where for me it didn't really make much sense, you know, if you've got a patient with 2 or 3 conditions, and you're checking in with that patient, and maybe just adjusting their meds or following up, and you only spend 15 min on the call with that patient. You should be able to bill at a higher rate, because you're still managing the condition around that patient's risk level. So I think this is a really good thing.
Lucy Zielinski:
Right and it's important to again grab those HCCs, so correct documentation and diagnosis codes. And Sarah, you could even speak to that right? We're changing versions.
Sarah Hartley:
Yeah, we this year, we're 67% in V28. 60% of that reimbursement is coming from version 28, the other 33% will be from version 24. So in 2026 100% version 28 documentation matters, this truly is a great step to recognize how complex the care is that's being provided.
Daniel Marino:
Yeah. So going now into V28, maybe you can just elaborate on that a little bit more. So folks really do have to pay attention to their documentation. The clinical documentation improvement initiatives that many organizations are undertaking is really what's going to support it. I'm assuming Sarah, as well as then, you know, supporting the HCC capture, and so forth.
Sarah Hartley:
That's correct. Our physicians have never been trained on how to document to get chronic conditions paid for now we have. We are changing the way that we're reimbursed. That's not. You know. We are providing great care. We need to be make sure that our doctors are documenting that, and we have clinicians and coders that you know are experienced and can really help our providers get to that next level to get to these extra G codes for those chronic conditions.
Daniel Marino:
Well, and I'm going to give a little bit of a plug here to the Lumina team for any of our listeners who are interested in understanding more around. V28, clinical documentation, improvement, care management. We have a fabulous team that has done a real nice job with working with organizations both around education, putting in new workflows and just helping organizations take advantage of that. I'm really proud of the work this group has done. So anybody interested in learning more please feel free to reach out. I want to switch to another area. And it's really probably more hospital focused, or it's really focused on some of the surgeons. And it's around global surgery. And I know there's a there's this continued shift inside of service from the acute arena to more of the ambulatory area. Lucy, maybe we could start with you. What's changed this year in some of the new surgical codes, or some of the big changes that are going to impact surgeries or that level of reimbursement.
Lucy Zielinski:
Yeah, Dan, I think it has a lot to do with some of the changes that we are seeing have to do with denials, because in the past we've had a global period, maybe of 90 days, but often care was transferred from one physician to the next. So maybe there was physician A did a couple of the visits post-OP. But then the physician, the patient, went to another physician, who also provided care during the post-OP period. So this new changes to the rule, address some of that.
Daniel Marino:
Hmm! That's interesting. Sarah, any additional thoughts.
Sarah Hartley:
Yeah, really, the goal here is to appropriately reflect the time and the resources involved in the follow up care that's being performed by the providers who work involved in furnishing the surgery. So giving credit where credit is due, basically.
Daniel Marino:
Well, and it seems to me, as I looked at it, there was a big post operative component that was tied to this. And again, I focus a lot on not only what's occurring in the fee for service arena, but also in the value-based care arena. This to me by adding on these additional codes and the G codes, and so forth. Allow for this transition to more to stronger post-operative care.
Sarah Hartley:
Correct, I would agree. It's really provide allowing the providers to provide that support appropriately and then be reimbursed appropriately for it as well.
Daniel Marino:
The last area that, as I was looking through, the rule seemed to me there was a focus on enhancing some of the financial opportunities for rural health clinics and federally qualified FQHCs. Federally qualified healthcare centers, health centers. What are some of the things, Sarah, that that you seen as you've looked at it, that are positive impacts or some of our RSCs FQHCs need to pay attention to?
Sarah Hartley:
Yeah. So what I see happening here is the alignment with other healthcare organizations in the way that rural health clinics and federally qualified healthcare centers are being reimbursed, starting with care, coordination services. And really aligning with other entities who are furnishing similar services. This year. Entities have to report individual CPT and HCPCs codes for those care coordination services, telehealth. They are aligning telehealth and allowing them to continue to bill for that technology for non-behavioral health visits here in the Rural Health community, but by reporting the HCSPCs and the G Codes on the claim that they, for the services that they furnish. So the big thing here is that they're aligning with other entities in the way that they are reimbursed.
Daniel Marino:
Yeah, well, I mean, that makes sense. And you know there's always some challenges in terms of you know how you bill it, and the reimbursement you get with the cost reporting, and all that other, all that other good stuff. But I think when you look at what has been, what they've included as additional codes and opportunities to really coordinate that care with other providers. I mean to me, this is a pretty big. This is a significant impact.
Sarah Hartley:
I would agree I would agree there. We I also see that they are allowing these rural health care centers and the FQHCs to bill and be paid for part B preventative vaccines and their administration. So that's a huge thing, too.
Daniel Marino:
Oh, really? Oh, yeah, that I didn't catch. Yeah, that's a good one. So also, you know, they could start to bill for some of the vaccinations and some of the reimbursement for activities, you know, for any vaccinations and so forth, that are being done by the FQHCs?
Sarah Hartley:
That's correct, and the payment will rates will align with other settings.
Daniel Marino:
Oh, that's great! Well, I ladies, I appreciate I appreciate your quick and dirty input and interpretation of the rule. There's a lot that's included in that. If any of our listeners are interested in finding out more, is there a place where maybe they can go for a summary, or any thoughts that we can direct them to.
Lucy Zielinski:
Well, so CMS puts out a fact sheet, which is nice. It's a high-level fact sheet. I usually read through the whole federal register rule, because there's some nice graphs, charts, more explanation, especially for coders and revenue cycle departments out there. I would recommend that they go directly to the to the Federal Register.
Daniel Marino:
Yeah. And I'm sure that's a real exciting read.
Lucy Zielinski:
It's a weekend long read. You were wondering what I was doing last weekend, Dan.
Daniel Marino:
No wonder, no wonder you look so well rested.
Lucy Zielinski:
Yeah. And then I would lastly, I would say, your local and national associations and specialty physician associations. They put together a nice summary specific to your specialty, so I would I would look there as well.
Daniel Marino:
Yeah, that's great. Well, and also, too, I'd love to direct everybody to the Lumina website. And if you do want any information we provide a lot of great information, great education, as well as some tools to help organizations, help providers think about how they need to train and change a lot of their coding activities to maximize a lot of these new rules that are coming down the pipe. Sarah, I want to turn to you. Thanks for all your help on this any parting words of wisdom.
Sarah Hartley:
No, we're just seeing it's becoming more and more important to document those chronic conditions in their interactions. So keep doing the good work.
Daniel Marino:
Yeah, and there's going to be a lot more to come, that is, for sure. Well, ladies, thank you really appreciate your time today. This was a great discussion. Love, to have you back to talk about some further changes, particularly around the V28. I think that's probably a big topic for us to cover sometime down the road.
Sarah Hartley:
Great look forward to it.
Daniel Marino:
And I want to thank everyone for tuning in and for listening until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.