Special Care We will begin shortly Home Management Fee Codes - - PowerPoint PPT Presentation

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Special Care Home Management Fee Codes

• Dr. Stan Oleksinski

FP Board; President March 30, 2020

Family Practice Webinar for Physicians & Staff

Welcome! Your microphone is muted. We will begin shortly…

Welcome – Your Participation

• All participant microphones are muted
• Please send your questions to Dr. Stan Oleksinski

anytime during the presentation: Email: modernization@sma.sk.ca, or Use the chat box: Stan will answer questions at the end of the presentation

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Where is the chat box?

Computers:

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Where is the chat box?

Computers: Phones/iPads: Step 1) Step 2)

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Your Participation

• Please send your questions to Dr. Stan Oleksinski

anytime during the presentation: Email: modernization@sma.sk.ca, or Use the chat box: Stan will answer questions at the end of the presentation

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Special Care Home Management Fee Codes Outline

• Context
• Special Care Home Management (SCHM)
• Pandemic Temporary Care Codes
• Operational Discussions & Resources
• FP Savings Reinvestment
• (FAQ’s) Frequently Asked Questions
• Questions and Answers with Dr. Oleksinski
• Close

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Context

• Work has been underway for over a year to modernize

how fee-for-service family physicians are paid for providing care to patients in Special Care Homes.

• This was not a cost-savings initiative. The fee code

description was broad and the services provided varied.

• The Ministry of Health, the SMA, and the Section of

Family Practice and FP Working Group dedicated time to updating the fee code to bring the services in line with current medical practices, to keep the changes cost neutral, and to align the work with three principles, Patient-Centered Care, Appropriateness, and Fairness.

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Special Care Home Management (SCHM)

Overview

SCHM Overview

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Special Care Home Management (SCHM) fees

• For continuous management of care for patients in special

care homes. All non-urgent medical interventions are performed during regular business hours.

• The fees have two components:

1) Indirect patient care, and 2) Direct patient care.

• Implementation will be April 1, 2020 in the new Payment

Schedule

Resource: Key Messages (included in webinar invitation)

SCHM: Indirect Patient Care (627A)

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Indirect Care: $24

• It is the bi-weekly continuous management of non-

urgent indirect patient care.

• The physician is the most responsible physician.
• A facility site visit is not required for billing.
• Service is provided during regular business hours. It

includes:

• Medication refills;
• Routine ordering and/or reviewing test results;
• Routine advice to family members/caregivers;
• Monitoring Anticoagulant Therapy (763A);
• All discussions with the staff of the facility;
• All telephone calls related to the patient’s routine care.

SCHM: Direct Care (628A)

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Direct Care: $60

• This fee is for a non-urgent medically necessary visit to

evaluate the patient's condition and to provide advice as necessary to the patient and/or the nursing/facility staff concerning the routine management of the patient.

• A face-to-face patient/physician encounter must be

made and the medical necessity for this visit must be fully documented.

• Direct patient care also includes indirect patient care.
• A minimum of one direct patient care visit is required per

patient per calendar year.

SCHM Urgent/Emergent Care

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• There will be no change if residents require medically

urgent care. This change is for non-urgent medical care performed during regular business hours.

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COVID-19 Pandemic Codes

Pandemic Codes for Virtual Care

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Two virtual care temporary codes can be used by physicians for resident care in Special Care Homes, instead of (5B).

• Pandemic Telephone Assessment (510A): $35.00

Direct patient care via telephone in real time (i.e., not text).

• Max. 2 per patient per day, with documentation.
• Pandemic Video Assessment (515A): $35.00

Patient care via secure healthcare appropriate virtual visit technology (not FaceTime or WhatsApp). Max. 2 per patient per day, with documentation.

Summary: When to Bill Codes in SCH

$24 every 2 weeks for Indirect care for non-urgent continuous management for phone, fax, email, med refills, etc. $60 for Direct care, a non-urgent and medically necessary visit, during regular business hours, up to a max of every 2 weeks. Bill when you visit, and document. $35 for Partial Assessment for urgent or medically necessary care. $12.50 for Telephone calls for urgent care after-hours/stats, in rare circumstances, billed by report. Or virtual care instead of (5B): Pandemic Telephone Assessment for direct patient care provided by telephone in real time (not text), and document. Pandemic Video Assessment (not FaceTime/WhatsApp), and document.

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(627A) (628A) (5B) (790A) (510A) (515A)

Operational Discussions with Facilities

Vacation/Time Off

• Plan for continuous care while away.

Establish a system of communication for Indirect care

• Create a time for non-urgent phone calls during regular business hours

at least disruptive times.

• Explore if emails/faxes can be batched with highest priority first.

Arranging Direct visits

• Plan a time when you would like to conduct medically necessary visits.
• Could a list of people who need visits be prepared in advance?
• Plan to do Medication reviews during the direct visits.

Coordinating Case conferences

• Formally scheduled, multi-disciplinary conference (2x/yr.)

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Resources

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Physician Resources:

• Documents: Key Messages, FAQ’s
• 2 webinars for physicians + staff

(Fri, March 26th and Monday, Mar 30th, 12pm) Facility Resources:

• Communication to SHA, Provincial Affiliates Resource

Group (PARG), Directors of Care, and Special Care Home Facilities

• Documents: Key Messages, FAQ’s
• Webinar for Facilities (Tuesday, Mar 31st, 10:30am)

Residents and Families:

• Handout

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FP: Savings Reinvested

Family Practice: Savings Reinvestment

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Reallocation of funds:

• Age Premiums Increased
• Remaining savings reinvested to 5B ($0.40)

Current Age Premiums New Age Premiums

55-64 15% 55-64 15% 65-74 25% 65-74 30% 75+ 35% 75-84 40% 85+ 50%

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SCHM Frequently Asked Questions

FAQ’s: TOPICS

• Getting Started: How to Bill
• Understanding the Codes
• Covering for a Physician
• Documentation
• Medical Necessity for Direct Care
• Urgent/Emergent Care
• What Else is Included/Excluded?
• Facilities
• Operational Considerations

Resource: FAQ handout (included in webinar invitation)

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FAQ’s: Getting Started: How to Bill

• 1. How do I start billing as the Most Responsible Physician

(MRP)?

• Must include the comment: “will be providing

continuous care”, identifying yourself as the MRP.

• Bill every 2 weeks, no further comments are required.
• Either Indirect/Direct code can initiate billing.

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Resource: FAQ handout

FAQ’s 2. When do I use each code?

$24 every 2 weeks for Indirect care for non-urgent continuous management for phone, fax, email, med refills, etc. $60 for Direct care, a non-urgent and medically necessary visit, during regular business hours, up to a max of every 2 weeks. Bill when you visit, and document. $35 for Partial Assessment for urgent or medically necessary care. $12.50 for Telephone calls for urgent care after-hours/stats, in rare circumstances, billed by report. Or virtual care instead of (5B): Pandemic Telephone Assessment for direct patient care provided by telephone in real time (not text), and document. Pandemic Video Assessment (not FaceTime/WhatsApp), and document.

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(627A) (628A) (5B) (790A) (510A) (515A)

FAQ’s: Understanding the Codes

• 3. Can I bill both (627A) Indirect care and (628A) Direct care

fee code for a patient in a two-week time period?

• Yes, but only one code will process.
• If you bill Indirect care (627A), and then visit the patient in

the same 14 day billing period and bill the Direct care code (628A), the system automatically converts the fee to the Direct care fee (higher amount) for those 2wks.

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Resource: FAQ handout

FAQ’s: Understanding the Codes

• 4. Can I bill the Pandemic codes (510A/515A) in the same

two-week time period as Indirect or Direct care?

• Yes, as long as it is medically necessary, it is not for

routine care (627A/628A), and it occurs at a different time

• f patient contact.

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Resource: FAQ handout

FAQ’s: Understanding the Codes

• 5. I have a palliative care patient in a Special Care Home and

their condition is worsening. How do I bill in this situation?

• Continue to bill an Indirect care or a Direct care code

every 2 weeks as usual.

• If you need to see that patient more frequently because
• f their condition, the extra visits should be billed as

partial assessment (5B) codes.

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Resource: FAQ handout

FAQ’s: Understanding the Codes

• 6. I have a palliative care patient in a Special Care Home and

am getting very frequent phone calls and faxes about their worsening condition. How do I bill in this situation?

• Telephone calls/facsimile/email for palliative care patients

are not included in Indirect/Direct care.

• Billed separately up to a maximum of three times in a day

if needed, using the (793A) fee code.

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Resource: FAQ handout

FAQ’s: Understanding the Codes

• 7. Can I bill phone calls (790A) to give urgent/emergent advice

for all my patients?

• If you’re a colleague covering, you can bill phone calls.
• If you are the MRP, phone calls after hours, stats, and/or

weekends can be billed as (790A), by report. This is to be considered a rare circumstance.

• If it is urgent, go in for a visit and bill other codes.

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Resource: FAQ handout

FAQ’s: Covering for a Physician

• 8. If a physician from another clinic is covering my patients

while I’m away, how will we navigate indirect billing?

• The covering physician can bill Indirect Care (627A),

stating: “Covering for Dr. first name; last name”.

• 9. If a physician from my clinic is covering my patients while

I’m away, how will we navigate indirect billing?

• The covering physician can bill Indirect Care (627A). No

comments required.

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Resource: FAQ handout

FAQ’s: Covering for a Physician

• 10. We have a large group of physicians and we rotate

coverage for Special Care Home patients. How do we bill in this situation?

• It will be left to the group of physicians to determine how

the income generated should be divided.

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Resource: FAQ handout

FAQ’s: Documentation

• 11. Do I need to document every time I bill Indirect care (627A)?
• Not for billing purposes.
• 12. Do I need to document every time I bill Direct care (628A)?
• Yes, a record of service is required

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Resource: FAQ handout

FAQ’s: Medical Necessity for Direct Care

• 13. Direct care visits require a medical necessity in order to

bill that code. How is medical necessity determined?

• A patient, family member, Special Care Home staff or

physicians may decide that a direct care visit is needed.

• 14. If I see a patient, give them treatment, and there is a

medical need to check on them 2 weeks later, can I bill Direct care?

• Yes, Direct Care can be billed up to every 2 weeks.

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Resource: FAQ handout

FAQ’s: Medical Necessity for Direct Care

• 15. If I visit a patient in a Special Care Home, is it

automatically a direct care visit?

• No, only if there is a medical need for them to be seen and

all elements of the direct care code, including documentation, are fulfilled.

• 16. If I’m at the facility and think of visiting a patient, can I bill

a Direct care code?

• Yes, if it is medically necessary, and documented.

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Resource: FAQ handout

FAQ’s: Medical Necessity for Direct Care

• 17. If I visit the staff in a Special Care Home, is it considered a

direct care visit?

• No, it is included as Indirect Care to the patient.
• 18. Some patients have relatives who want to be frequently

updated on their relative’s status. How do I get compensated for that?

• Routine briefing to relatives is part of the Indirect/Direct

care service.

• If requests are too frequent, set up a Case Conference

(42B/44B), formally scheduled, max 2/yr./patient.

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Resource: FAQ handout

FAQ’s: Urgent/Emergent Care

• 19. Are Special Calls excluded in SCHM?
• Yes, Special Calls are excluded for urgent/emergent

circumstances and are billed in addition.

• 20. What is considered urgent/emergent?
• A condition requires care in a timely manner, within 24 hrs.

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Resource: FAQ handout

FAQ’s: What Else is included/Excluded

• 21. Are premiums and surcharges included?
• No premiums or surcharges are allowed.

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Resource: FAQ handout

FAQ’s: What Else is included/Excluded

• 22. Are admissions included in Special Care Home Management?
• It depends if the admission into the facility:
• Is done indirectly, it is Indirect Care (627A),
• Includes a visit with only a history and a physical, it is

Direct care (628A), or

• All components of a complete assessment (3B) are

performed and documented. Note: If a (3B) is billed upon admission, begin billing Indirect/Direct the next day.

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Resource: FAQ handout

FAQ’s: What Else is included/Excluded

• 23. How do I bill a Medication Review?
• Without the patient and without a multi-disciplinary team, the

service is included in Indirect care (627A).

• Without the patient but with a multi-disciplinary team, bill a

case conference (42B, 43B, 44B, max 2 per year).

• With the patient, bill Direct care (628A) if all the criteria has

been met. The medication review is considered medically necessary to require a Direct care visit.

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Resource: FAQ handout

FAQ’s: What Else is included/Excluded

• 24. How do I bill a Case Conference?
• A Case Conference (42B/44B) is not included in these fees

and is payable in addition to Special Care Home Management, when the service provided meets the Payment Schedule criteria (2 per year).

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Resource: FAQ handout

FAQ’s: Facilities

• 25. What facilities are included in Special Care Home

Management?

*Community, northern, regional, provincial, rehabilitation or district as defined by The Facility Designation Regulations.

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Special Care Homes include: a) Convalescent care b) Long-term care or long-stay care c) Palliative care d) Respite Care Hospitals* include: e) Convalescent care f) Long-term care or long-stay care g) Palliative care h) Respite Care i) Level 4 care

FAQ’s: Facilities

• 26. I look after patients who live in Personal Care Homes. Can

I use these codes to bill for them?

• No. These patients remain excluded as defined in The

Personal Care Homes Act.

• 27. How do I bill for patients who are in a hospital but who no

longer need ongoing hospital care and are waiting for a special care home placement?

• Once a patient is no longer deemed to be an acute care

hospital inpatient, begin using the SCHM codes.

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Resource: FAQ handout

FAQ’s: Operational Considerations

• 28. Are there things I can do help this change go more

smoothly with facilities?

• It is recommended to have a conversation with your

facilities about the following:

• Vacation/Time Off
• Establish a system of communication for Indirect care
• Establish a system of arranging Direct visits
• Coordinate Case Conferences

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Resource: FAQ handout

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Questions and Answers with

• Dr. Stan

Oleksinski

Special Care Home Management

Questions and Answers with Dr. Oleksinski

• All participant microphones are muted
• Please send your questions to Dr. Stan Oleksinski

anytime during the presentation: Email: modernization@sma.sk.ca, or Use the chat box:

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Where is the chat box?

Computers: Phones/iPads: Step 1) Step 2)

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Contact:

• Family Practice President, Stan Oleksinski;

dr.oleksinski@westhillmedical.com,

• r
• Family Practice Board Chair, Carla Holinaty;

carla.holinaty@usask.ca.

For More Information or Discussion

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Thank you

Additional Slides

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Payment Schedule Modernization (PSM)

Payment Schedule

Modernization

Payment Schedule Modernization (PSM) What is it?

• PSM is the first ever comprehensive review of the Payment

Schedule.

• This process does not have new money. It is cost neutral and

savings are kept within the Section.

• It includes changing descriptors and prices of current fee

codes, up to 2 times per year.

• Physicians lead the process for developing recommendations,

with support from SMA staff. The Section collaborates with the Ministry on a structured timeline for (PSRC) Payment Schedule Review Committee meetings (January & June). The Minister of Health has final approval.

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Payment Schedule

Modernization

PSM approach

• PSM provides opportunities to ensure fee-code descriptors

align with current standards of medical practice, clarify descriptors to reduce variation in billing practices, and ensure fees accurately reflect the service provided.

• The project is guided by overarching principles:

51 Patient- centered Care Appropriateness Fairness

Payment Schedule

Modernization

“Let’s make things clear, and do the right thing.”

~ Dr. Shane Sheppard, Chair, Economics Committee

PSM Recommendation

A Section recommendation is ready for PSRC when: 1) Codes are modernized in alignment with PSM principles; 2) Savings and reinvestment are identified (cost neutral); 3) Section members are informed with opportunities for feedback; and 4) Section Executive builds consensus on recommendation and receives MSB agreement, to forward the recommendation to PSRC.

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Payment Schedule

Modernization

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626A Fee Code Change

Routine Nursing Home Visits

Family Practice: Why was 626A prioritized?

This was not a cost-savings initiative. In 2013, it was found that there was ambiguity in how the current fee code was written, and large variation in how it was applied. There were concerns with Principles of:

• Patient Centered Care,
• Appropriateness, &
• Fairness.
• The Ministry of Health, the SMA, and the Section of Family

Practice have been working on the update.

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Family Practice: Process for 626A Revision

The process began in 2017. The Working Group grew its provincial representation in Jan 2019 and did the following:

• Examined data:
• 626A billing data, Cross- Canada jurisdictional scan of fees,

Provincial Special Care Home Guidelines, and related issues.

• Engaged key stakeholders:
• FP Section members, potentially impacted physicians, Ministry of

Health, SHA physicians and administrative leaders, and Provincial Affiliates Resource Group (PARG).

The FP Board supported changing 626A as an improvement

• pportunity for senior’s care.

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