Maximizing reimbursement in COPD management

With a basic understanding of the BPCI Advanced initiative, quality metrics and recent CMS changes affecting reimbursement in COPD, both primary care physicians and specialists will be better prepared to adjust to the bundled payment system. 

BPCI Advanced

BPCI Advanced, which runs through December 2023, is a single-model payment system in which hospitals voluntarily participate.5 The model employs a “single, retrospective bundled payment” for 29 inpatient diagnoses and three outpatient procedures, and the payment covers the anchor stay and the following 90-day period starting from the date of discharge or procedure.6

Benchmark prices are provided to hospitals in advance and are based on historical patterns of spending, patient case-mix and efficiency in resource use by the hospital. Retrospectively, the target price is adjusted for patient complexity alone, and CMS considers all conditions that are actively managed during the admission. Finally, the target price is adjusted for performance on quality measures.7

Data from the first phase of BPCI shows the average bundled payment for a 90-day COPD-related admission is $18,055.8 Strategies to maximize payments under BPCI Advanced should revolve around thoroughly documenting patient complexity, minimizing length of stay, reducing readmission rates and adhering to quality metrics as explained below. 

Quality metrics

CMS defines three quality measures for all inpatient and outpatient clinical episodes in BPCI Advanced. The first metric must be fulfilled for each episode, while the second and third are based on hospital-wide data from previous years.9 There are currently no quality metrics specific to COPD admissions.

1. Advance care plan: To successfully fulfill this metric, a Medicare provider must submit a qualifying CPT code demonstrating that an advance care plan was discussed with the patient. This can be coded at any point within 12 months prior to the end of the episode, except for when the patient is under the care of an emergency physician. The qualifying codes include: CPT billing codes 99497 and 99498 and CPT II tracking codes 1123F and 1124F.10
2. All-cause hospital readmission measure: This metric estimates the risk-standardized rate of unplanned readmissions on a hospital-wide level. There are several exclusions, including those discharged against medical advice and admissions for psychiatric diagnoses, rehabilitation and medical treatment of cancer. A readmission to any hospital will count against the index hospital.11
3. CMS patient safety indicators: This metric is a weighted average based on several years of hospital-wide data. Data specific to medicine patients include pressure ulcer rates, iatrogenic pneumothorax rates, in-hospital fall with hip fracture rates and unrecognized accidental puncture or laceration rates.12

Transitional care management services

While the role of close follow-up in reducing readmissions in COPD remains unclear, the transition period following hospital discharge is high-risk, particularly in patients with severe disease or multiple comorbidities.13,14,15 Implemented in 2013, CPT codes for transitional care management services are specific to the period of care following discharge from the hospital.16 Either the primary care physician or specialist can bill for this care.

Despite providing care that qualifies as transitional care from a billing standpoint, many providers continue to bill for standard office visits. Billing for transitional care (CPT 99495 or 99496) yields $166.50 and $234.97, respectively. The standard office visit addressing moderate to high-severity problems in established patients (CPT codes 99214 and 99215) brings in significantly less ($110.28 and $147.76) for often equivalent services.17

Transitional care management services codes:

• CPT 99495: Includes communication (direct contact, telephone, electronic) with the patient/caregiver within two business days of discharge from an inpatient hospital setting, medical decision making of at least moderate complexity during service period and face-to-face visit within 14 calendar days of discharge.
• CPT 99496: Includes communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge from an inpatient hospital setting, medical decision making of high complexity during the service period and face-to-face visit within seven calendar days of discharge.

Chronic care management services

Given the complexity of COPD patients, providers should consider that they can bill for chronic care management services as often as monthly. While the primary care physician is most commonly managing the patient’s care, this can instead be billed by the specialist if he or she is coordinating services.18 CMS pays $92.98, $46.49, $42.17 and $83.97 for codes 99487, 99489, 99490 and 99491, respectively.19

Chronic care management services codes:

• CPT 99487: Complex chronic care management services with required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• CPT 99489: Each additional 30 minutes.
• CPT 99490: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.
• CPT 99491: Chronic care management services, provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified healthcare professional time, per calendar month, with required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.

Chronic care remote physiologic monitoring

As of 2019, CMS offers three CPT codes for chronic care remote physiologic monitoring and six for interprofessional internet consultation.20 The applications of telehealth practices in COPD are expansive, including consultation services, patient monitoring, education and pulmonary rehabilitation (PR).21

Despite established benefits of institution-based pulmonary rehabilitation, CMS payments remain low, averaging $55.90 for 2019, and accessibility poor.22,23 By implementing remote PR, practitioners cut costs and broaden access without sacrificing benefits to the patients.24 Combining additional telehealth services with remote PR gives providers the opportunity to bill for remote patient monitoring.

The new codes are as follows:25 

• CPT 99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.
• CPT 99454: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
• CPT 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

Notes:

1. “COPD costs.” Atlanta: Centers for Disease Control and Prevention, 2018. Available from: bit.ly/30GrzC3.
2. Ibid.
3. Ibid.
4. “Addressing the burden of chronic obstructive pulmonary disease in rural America: Policy brief and recommendations.” Charlotte: National advisory Committee on Rural Health and Human Services, 2018. Available from: bit.ly/32wzKTt.
5. “BPCI Advanced.” Baltimore: Centers for Medicare & Medicaid Services, 2019. Available from: bit.ly/2CO5ypD.
6. Ibid.
7. Ibid.
8. Maddox KE, Orav EJ, Zheng J, Epstein AM. “Evaluation of Medicare’s bundled payments initiative for medical conditions.” The New England Journal of Medicine. 2018; 379:260-269.
9. BPCI Advanced.
10. “Advance Care Plan (NQF #0326) National Quality Strategy Domain: Communication and Coordination.” Baltimore: Centers for Medicare & Medicaid Services, 2019. Available from: bit.ly/2XXNFhG.
11. “Hospital-Wide All-Cause Unplanned Readmission Measure (NQF #1789) National Quality Strategy Domain: Communication and Care Coordination.” Baltimore: Centers for Medicare & Medicaid Services, 2019. Available from: bit.ly/2xOtnga.
12. “CMS Patient Safety Indicators PSI 90 National Quality Strategy Domain: Patient Safety.” Baltimore: Centers for Medicare & Medicaid Services, 2019. Available from: bit.ly/32xOS2U.
13. Budde J, Agarwal P, Mazumdar M, Braman SS. “Follow-up soon after discharge may not reduce COPD readmissions.” Chronic Obstr Pulm Dis. 2019; 6(2): 129-131
14. Song J, Walter M. “Effect of early follow-up after hospital discharge on outcomes in patients with heart failure or chronic obstructive pulmonary disease: a systematic review.” Ont Health Technology Assessment Series. 2017; 17(8): 1-37.
15. Gavish R et al. “The association between hospital readmission and pulmonologist follow-up visits in patients with COPD.” Chest. 2015; 148(2): 375-381.
16. “Transitional Care Management Services.” Baltimore: Centers for Medicare & Medicaid Services, 2019. Available from: go.cms.gov/2SjfMa6.
17. McManus M, White P, Schmidt A, Kanter D, Salus T. “2019 Coding and Reimbursement Tip Sheet for Transition from Pediatric to Adult Health Care.” Washington D.C.: The National Alliance to Advance Adolescent Health, 2019. Available from: bit.ly/2Y7sduW.
18. “Chronic Care Management Services.” Baltimore: Centers for Medicare & Medicaid Services, 2016. Available from: go.cms.gov/2XSHVpH.
19. McManus.
20. “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019.” Baltimore: Centers for Medicare & Medicaid Services, 2018. Available from: go.cms.gov/2OgVdat.
21. Selzler AM, Wald J, Sedeno M, et al. “Telehealth pulmonary rehabilitation: A review of the literature and an example of a nationwide initiative to improve the accessibility of pulmonary rehabilitation.” Chron Respir Dis. 2017;15(1):41–47.
22. “COPD Costs.”
23. Selzler.
24. Ibid.
25. Wicklund E. “CMS to reimburse providers for remote patient monitoring services.” mHealth Intelligence. Nov. 2, 2018. Available from: bit.ly/2Jy8LxL.