Last week, CMS issued their 2025 Physician Fee Schedule Proposed Rule. These rules will apply to any therapy services provided in an outpatient/Med B setting, including outpatient clinics, skilled nursing facilities, and home health. Below are a few updates that facility-based therapists and billers should be aware of if the rule becomes final for 2025 later in the year. Payment Rate Update CMS proposes a conversion factor of $32.36, which represents a decrease of $0.93 (or 2.80%) from the current CY 2024 conversion factor of $33.29. Average payment rates are proposed to be reduced by a net 2.93% in 2025 compared to the average amount these services are being paid for most of 2024. Annual Therapy (KX Modifier) Threshold Every year, CMS establishes a revenue threshold that, when exceeded, a KX modifier must be applied to each billed service line to indicate that services remain skilled and necessary. For 2025, that annual threshold amount is $2410 for physical and speech therapy COMBINED and a separate $2410 for occupational therapy. Therapy Plan of Care Certification by Physicians/Extenders Currently, CMS requires outpatient therapy plans of care to be certified (signed and dated) by a physician or extender within 30 days of the start of care date. The 2025 Rule proposes that, if a patient presents with an order that is signed by the physician/extender indicating the specific therapy discipline and evidence can be submitted showing that the therapy plan of care has been delivered to the physician/extender within 30 days of the start of care date, that the order will suffice for physician/extender certification of therapy services without the plan of care being signed. While the presence of a valid order OR a certified plan of care within 30 days should be sufficient to get the outpatient claim paid, I still think it is best practice to have both to ensure compliance. In the Proposed Rule, CMS is also soliciting provider comments regarding regulations for timeliness of physician/extender changes to therapist-established plans of care and a 90 day time limit for the time period between the initial order and the start of therapy. Updates to Telehealth Currently, certain outpatient physical, occupational, and speech therapy codes can be delivered via telehealth through December 31, 2024. The Proposed Rule does nothing to extend this provision, so further Congressional action would be required for telehealth services to be extended into January 2025. On January 1, 2024, CMS added 3 new CPT codes for caregiver training (97550, 97551, and 97552). The 2025 Proposed Rule would add these three codes to the approved list of codes that can be delivered via telehealth, as long as those services are approved beyond December 31, 2024. The Proposed Rule can be found at https://lnkd.in/g3An5iXH. And comments are due to CMS by 5:00 PM on September 9, 2024.
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Director of Compliance and Clinical Services, Occupational Therapist - Carolina Therapy Services and Trinity Rehab
Last week, CMS issued their 2025 Physician Fee Schedule Proposed Rule. These rules will apply to any therapy services provided in an outpatient/Med B setting, including outpatient clinics, skilled nursing facilities, and home health. Below are a few updates that facility-based therapists and billers should be aware of if the rule becomes final for 2025 later in the year. Payment Rate Update CMS proposes a conversion factor of $32.36, which represents a decrease of $0.93 (or 2.80%) from the current CY 2024 conversion factor of $33.29. Average payment rates are proposed to be reduced by a net 2.93% in 2025 compared to the average amount these services are being paid for most of 2024. Annual Therapy (KX Modifier) Threshold Every year, CMS establishes a revenue threshold that, when exceeded, a KX modifier must be applied to each billed service line to indicate that services remain skilled and necessary. For 2025, that annual threshold amount is $2410 for physical and speech therapy COMBINED and a separate $2410 for occupational therapy. Therapy Plan of Care Certification by Physicians/Extenders Currently, CMS requires outpatient therapy plans of care to be certified (signed and dated) by a physician or extender within 30 days of the start of care date. The 2025 Rule proposes that, if a patient presents with an order that is signed by the physician/extender indicating the specific therapy discipline and evidence can be submitted showing that the therapy plan of care has been delivered to the physician/extender within 30 days of the start of care date, that the order will suffice for physician/extender certification of therapy services without the plan of care being signed. While the presence of a valid order OR a certified plan of care within 30 days should be sufficient to get the outpatient claim paid, I still think it is best practice to have both to ensure compliance. In the Proposed Rule, CMS is also soliciting provider comments regarding regulations for timeliness of physician/extender changes to therapist-established plans of care and a 90 day time limit for the time period between the initial order and the start of therapy. Updates to Telehealth Currently, certain outpatient physical, occupational, and speech therapy codes can be delivered via telehealth through December 31, 2024. The Proposed Rule does nothing to extend this provision, so further Congressional action would be required for telehealth services to be extended into January 2025. On January 1, 2024, CMS added 3 new CPT codes for caregiver training (97550, 97551, and 97552). The 2025 Proposed Rule would add these three codes to the approved list of codes that can be delivered via telehealth, as long as those services are approved beyond December 31, 2024. The Proposed Rule can be found at https://lnkd.in/ecYnbhj5. And comments are due to CMS by 5:00 PM on September 9, 2024.
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Last week, CMS issued their 2025 Physician Fee Schedule Proposed Rule. These rules will apply to any therapy services provided in an outpatient/Med B setting, including outpatient clinics, skilled nursing facilities, and home health. Below are a few updates that facility-based therapists and billers should be aware of if the rule becomes final for 2025 later in the year. Payment Rate Update CMS proposes a conversion factor of $32.36, which represents a decrease of $0.93 (or 2.80%) from the current CY 2024 conversion factor of $33.29. Average payment rates are proposed to be reduced by a net 2.93% in 2025 compared to the average amount these services are being paid for most of 2024. Annual Therapy (KX Modifier) Threshold Every year, CMS establishes a revenue threshold that, when exceeded, a KX modifier must be applied to each billed service line to indicate that services remain skilled and necessary. For 2025, that annual threshold amount is $2410 for physical and speech therapy COMBINED and a separate $2410 for occupational therapy. Therapy Plan of Care Certification by Physicians/Extenders Currently, CMS requires outpatient therapy plans of care to be certified (signed and dated) by a physician or extender within 30 days of the start of care date. The 2025 Rule proposes that, if a patient presents with an order that is signed by the physician/extender indicating the specific therapy discipline and evidence can be submitted showing that the therapy plan of care has been delivered to the physician/extender within 30 days of the start of care date, that the order will suffice for physician/extender certification of therapy services without the plan of care being signed. While the presence of a valid order OR a certified plan of care within 30 days should be sufficient to get the outpatient claim paid, I still think it is best practice to have both to ensure compliance. In the Proposed Rule, CMS is also soliciting provider comments regarding regulations for timeliness of physician/extender changes to therapist-established plans of care and a 90 day time limit for the time period between the initial order and the start of therapy. Updates to Telehealth Currently, certain outpatient physical, occupational, and speech therapy codes can be delivered via telehealth through December 31, 2024. The Proposed Rule does nothing to extend this provision, so further Congressional action would be required for telehealth services to be extended into January 2025. On January 1, 2024, CMS added 3 new CPT codes for caregiver training (97550, 97551, and 97552). The 2025 Proposed Rule would add these three codes to the approved list of codes that can be delivered via telehealth, as long as those services are approved beyond December 31, 2024. The Proposed Rule can be found at https://lnkd.in/g3An5iXH. And comments are due to CMS by 5:00 PM on September 9, 2024.
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🚩 PMG Packages for Outpatient Care Outpatient care is medical assistance that a patient receives without hospitalization, i.e., in outpatient conditions. This includes doctor consultations, diagnostics, procedures, and treatments that do not require a prolonged stay in the hospital. This package aims to help ordinary people and individuals with epilepsy and related conditions receive various types of outpatient care for free, including consultations, tests, analyses, and more. In other words, medical facilities are obliged, if necessary, to provide free services such as MRI, EEG, X-rays, and many others within the framework of this package. Consumables (such as X-ray film, etc.) should also be provided by the medical institution under this package. To receive services from this package for free, it is necessary to obtain a referral from a primary care physician (family doctor) or a treating physician. Treatment for epilepsy may be prescribed by a neurologist, pediatric neurologist, psychiatrist, or pediatric psychiatrist. No referral is required for a consultation with a psychiatrist. Choose a medical institution that has an agreement with the National Health Service of Ukraine (NHSU) and schedule an appointment. 📌 You can check whether the institution has the appropriate agreement by contacting them directly or by checking the information on the official NHSU website: https://lnkd.in/dYFgN9iA For a visit to a neurologist, an electronic referral is required, which can be issued by a family doctor, therapist, or pediatrician with whom a declaration is concluded. Forced migrants do not necessarily need to have a declaration – they can contact any primary care physician. 📌 For more detailed information about the scope of services included in this and other packages, refer to the patient guide from the NHSU: https://cutt.ly/MwT15VOi Subscribe to our page to be the first to learn about news and help spread important information. The "Guaranteed!" initiative is implemented by CF Patients of Ukraine in partnership with the Ministry of health of Ukraine and Національна служба здоров'я України, with the support of the USAID Ukraine: https://lnkd.in/dz-6TPTB Project "Health Reform Support."
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Tackling Waiting Times in Malta's Outpatient Departments: A Call for Efficiency** In the bustling healthcare landscape of Malta, one issue looms large for patients seeking medical care: waiting times in outpatient departments. For many, the frustration of waiting for hours after securing an appointment months in advance has become an all-too-familiar experience. This not only tests the patience of patients but also raises concerns about the efficiency and effectiveness of the healthcare system. **The Waiting Game: Understanding the Problem** Waiting times in outpatient departments can stem from various factors, including administrative bottlenecks, scheduling inefficiencies, staff shortages, and unexpected emergencies. Despite efforts to improve the system, patients continue to endure long waits, diminishing the quality of their healthcare experience. **A Realistic Solution: Technology to the Rescue** While there is no one-size-fits-all solution to this complex issue, embracing technology can pave the way for tangible improvements. One practical and realistic solution is the implementation of a digital appointment notification system. This system would utilize text messages or mobile apps to alert patients when their appointment is approaching, allowing them to arrive closer to their designated time slot. **How It Works: Streamlining Patient Flow** Imagine receiving a text message or app notification reminding you of your upcoming appointment and providing an estimated arrival time based on current patient flow. With this information in hand, patients can plan their visit more effectively, arriving just in time for their consultation without having to endure lengthy waits in the waiting room. **Benefits Abound: Efficiency and Patient Satisfaction** Such a system offers numerous benefits for both patients and healthcare providers. By reducing wait times, it optimizes the use of resources and minimizes overcrowding in waiting areas. Patients experience shorter wait times, leading to increased satisfaction and a more positive overall healthcare experience. Moreover, healthcare providers can better manage their schedules, leading to improved productivity and reduced stress levels among staff. **Moving Forward: Collaboration for Change** Implementing a digital appointment notification system requires collaboration among healthcare providers, policymakers, and technology experts. It's a tangible step towards addressing the root causes of long waiting times in outpatient departments and enhancing the quality of care provided to patients in Malta. **Conclusion: Towards a More Efficient Future** In the journey towards a more efficient healthcare system, tackling waiting times in outpatient departments is a crucial milestone. By embracing technology and implementing practical solutions like digital appointment notifications, Malta can pave the way for a future where patients receive timely and high-quality care.
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Outpatient Clinic Sales See Surge in Specialized Services and Multidisciplinary Centers The outpatient clinics market is predicted to develop at a CAGR of 4.2% attaining a value of US$ 40,761.7 million by the end of 2023. The outpatient clinics market size is projected to be valued at US$ 61,372.4 million by 2033. The demand for convenient and affordable healthcare services is propelling the global outpatient clinics market expansion. A comprehensive range of medical services, diagnostic procedures, and treatments are offered at outpatient clinics without the requirement for an overnight hospital stay. With the outpatient treatment demand rising globally, outpatient clinics need to provide effective and accessible healthcare. Contemporary advancements in medical technology have ushered in a new era, providing pharmaceuticals and cutting-edge equipment that facilitate medical interventions, diagnostic procedures, and surgical interventions without the need for extended hospital stays. Read the entire article below to find more details on what's propelling outpatient clinic market expansion. https://lnkd.in/gSPsVANC For over 40 years, Expeditor has been a customized patient flow efficiency solution that has kept up with the many changes in ASCs and outpatient clinics, and therefore offer turnkey solutions for ASCs and Outpatient Clinics. Let us show you how our life safety equipment provides ASCs the most affordable and advanced technology solution on the market. In addition, if you are looking for an organization that is focused on streamlining communications, increasing patient flow efficiency and improving The Patient Experience in your outpatient clinic, look no further than Expeditor. Let us show you how our technology has increased patient flow efficiency while improving the Patient Experience for over 8,000 clients...Contact Us today! expeditor.com #patientexperience #patientflow #asc #ambulatorysurgery #ambulatorysurgerycenter #patientflowefficiency
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I enhance and elevate careers of mid-revenue cycle healthcare professionals. Published author, podcast host. Former ACDIS Director.
Chronic condition reporting is more important than ever these days, but also a subject of increasing scrutiny. When a patient comes in for an outpatient visit with a chronic condition, should we report it? The TL;DR answer (to me at least) appears to be that it is the provider’s responsibility to document that the condition affected the care or management of the patient during the encounter. If he or she does, it can be reported. Section IV of the ICD-10-CM Official Guidelines for Coding and Reporting (which pertain to outpatient services) states the following: · Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) · Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. What does Coding Clinic say? Copyright and length restrictions prohibit me from restating these in full, but your best references are: Coding Clinic Third Quarter 2021, pp. 32-33, “Reporting additional diagnoses in outpatient setting – clarification,” which states: “Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter.” Coding Clinic followed that up with an entry in Q2 2022, stating that such a condition could be reported for HCC coding purposes from another encounter in the same year, but only if it met the same requirement (i.e., the condition affected care or needed management). From that entry: "The Coding Clinic advice that additional diagnoses in the outpatient setting must affect care and management of the patient was related to the coding for a single specific encounter in time. Coding for risk adjustment, such as for HCCs, involves the collection of known current chronic conditions over the course of a year. While a patient's chronic condition may not have affected care or needed management during a specific individual outpatient visit, the chronic condition would be captured for HCC coding from other visits, encounters, or hospitalizations when the chronic condition affected care or needed management." Thanks to Jim Kennedy for providing me references on this topic. How do you handle chronic condition reporting in your organization? Do they differ for HCC reporting vs. standard profee coding? Leave your comments below.
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The physical facilities of an Outpatient Department (OPD) typically include examination rooms, waiting areas, registration counters, nursing stations, and sometimes minor procedure rooms. These spaces are designed to facilitate the efficient flow of patients through the outpatient services, ensuring comfort and privacy during consultations. Additionally, OPD facilities may have diagnostic services such as laboratories and imaging departments nearby for convenience. The layout and design aim to create a patient-friendly environment while supporting the workflow of healthcare professionals. In a hospital's Outpatient Department (OPD), you can expect to find various physical facilities designed to cater to the needs of patients seeking ambulatory care. These may include: Waiting Area: A comfortable space for patients to wait before their appointments. Registration Desk: Where patients check in and complete necessary paperwork. Examination Rooms: Equipped for patient consultations and basic examinations. Nursing Stations: Staffed areas for nurses to coordinate patient care, handle inquiries, and assist physicians. Consultation Rooms: Spaces where doctors meet with patients for assessments and discussions. Procedure Rooms: For minor procedures that can be performed on an outpatient basis. Diagnostic Services: Facilities for various diagnostic tests, such as laboratories and imaging centers. Pharmacy: Often located nearby for the convenience of filling prescriptions. Information Desk: To assist patients in finding their way and obtaining necessary information. Comfortable Seating: Throughout the OPD to enhance the overall patient experience. ASCI Post Graduate Diploma in Hospital Management
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Documenting chronic conditions and documenting them properly is key! We need the whole picture to treat patients. Also us coders need this important info, especially when medical necessity becomes an issue.
I enhance and elevate careers of mid-revenue cycle healthcare professionals. Published author, podcast host. Former ACDIS Director.
Chronic condition reporting is more important than ever these days, but also a subject of increasing scrutiny. When a patient comes in for an outpatient visit with a chronic condition, should we report it? The TL;DR answer (to me at least) appears to be that it is the provider’s responsibility to document that the condition affected the care or management of the patient during the encounter. If he or she does, it can be reported. Section IV of the ICD-10-CM Official Guidelines for Coding and Reporting (which pertain to outpatient services) states the following: · Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) · Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. What does Coding Clinic say? Copyright and length restrictions prohibit me from restating these in full, but your best references are: Coding Clinic Third Quarter 2021, pp. 32-33, “Reporting additional diagnoses in outpatient setting – clarification,” which states: “Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter.” Coding Clinic followed that up with an entry in Q2 2022, stating that such a condition could be reported for HCC coding purposes from another encounter in the same year, but only if it met the same requirement (i.e., the condition affected care or needed management). From that entry: "The Coding Clinic advice that additional diagnoses in the outpatient setting must affect care and management of the patient was related to the coding for a single specific encounter in time. Coding for risk adjustment, such as for HCCs, involves the collection of known current chronic conditions over the course of a year. While a patient's chronic condition may not have affected care or needed management during a specific individual outpatient visit, the chronic condition would be captured for HCC coding from other visits, encounters, or hospitalizations when the chronic condition affected care or needed management." Thanks to Jim Kennedy for providing me references on this topic. How do you handle chronic condition reporting in your organization? Do they differ for HCC reporting vs. standard profee coding? Leave your comments below.
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TLDR: Reminder - There are no chronic conditions that can be captured without supporting documentation. Each code must be supported in the medical record to be compliant for risk adjustment submission/payment. Thanks for the excellent write up on one of my favorite topics Brian Murphy! #riskadjustment #compliance #medicareadvantage #compliantcodint #hcc
I enhance and elevate careers of mid-revenue cycle healthcare professionals. Published author, podcast host. Former ACDIS Director.
Chronic condition reporting is more important than ever these days, but also a subject of increasing scrutiny. When a patient comes in for an outpatient visit with a chronic condition, should we report it? The TL;DR answer (to me at least) appears to be that it is the provider’s responsibility to document that the condition affected the care or management of the patient during the encounter. If he or she does, it can be reported. Section IV of the ICD-10-CM Official Guidelines for Coding and Reporting (which pertain to outpatient services) states the following: · Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) · Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. What does Coding Clinic say? Copyright and length restrictions prohibit me from restating these in full, but your best references are: Coding Clinic Third Quarter 2021, pp. 32-33, “Reporting additional diagnoses in outpatient setting – clarification,” which states: “Coding professionals should not assign codes based solely on diagnoses noted in the history, problem list and/or a medication list. It is the provider’s responsibility to document that the chronic condition affected care and management of the patient for that encounter.” Coding Clinic followed that up with an entry in Q2 2022, stating that such a condition could be reported for HCC coding purposes from another encounter in the same year, but only if it met the same requirement (i.e., the condition affected care or needed management). From that entry: "The Coding Clinic advice that additional diagnoses in the outpatient setting must affect care and management of the patient was related to the coding for a single specific encounter in time. Coding for risk adjustment, such as for HCCs, involves the collection of known current chronic conditions over the course of a year. While a patient's chronic condition may not have affected care or needed management during a specific individual outpatient visit, the chronic condition would be captured for HCC coding from other visits, encounters, or hospitalizations when the chronic condition affected care or needed management." Thanks to Jim Kennedy for providing me references on this topic. How do you handle chronic condition reporting in your organization? Do they differ for HCC reporting vs. standard profee coding? Leave your comments below.
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Effective Sept. 1, 2024, UHC require prior authorization for the following services delivered in multidisciplinary offices and outpatient hospital settings, excluding services in the home: Physical therapy (PT) Occupational therapy (OT) Speech therapy (ST) Medicare-covered chiropractic services (when billed with the AT-modifier) Multidisciplinary practices may encompass settings where physical therapy, occupational therapy, speech therapy and chiropractic care are all provided within a single facility or office. Alternatively, they could refer to individual practices each specializing in a single discipline. Prior authorization is required for the following place of service codes: 11 Office 19 Off-Campus Outpatient Hospital 22 On-Campus Outpatient Hospital 24 Ambulatory Surgical Center 49 Independent Clinic 62 Comprehensive Outpatient Rehabilitation Facility This applies to UnitedHealthcare® Medicare Advantage nationally, excluding Dual Complete Special Needs Plans (SNP). Current prior authorization requirements in Arkansas, Georgia, South Carolina and New Jersey for outpatient therapies continues as previously deployed and will now include Medicare-covered chiropractic services. https://lnkd.in/d_KR4UKi #UHC #UnitedHealthCare #RCM #USHealthCare #AR #Billing #MedicalBilling #Outsourcing
Outpatient therapy and chiropractic prior authorization requirements
uhcprovider.com
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