From a Fair Market Value (FMV) perspective, the process of tying quality metrics into provider compensation involves simultaneously aligning incentives with healthcare quality and outcomes while ensuring the compensation remains competitive and compliant with regulatory standards.

However, before you ever add quality incentives to a compensation plan, begin by asking “Why?”. Do I have a particular concern about my outcomes today? Is there a particular group / specialty that I need assistance from to improve outcomes? Has my hospital been charged penalties for outcomes that I could address / improve by aligning these metrics with compensation plans?

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Before we discuss documentation guidelines, let’s define psychotherapy. Psychotherapy, also known as talk therapy, is a type of therapy during which the provider uses a series of techniques to treat the mental and emotional health problems of a patient.

When coding psychotherapy, there are several code combinations available, depending on the type of service performed and whether it was performed with or without an Evaluation and Management (“E/M”) service.

CPT^® codes 90832, 90834, and 90837 are assigned when only the psychotherapy portion was performed during the encounter. All three (3) codes are based on time and range from 30-60 minutes.

If an E/M ...

If you haven’t already, you should utilize the Medicare Preventive Services education tool from The Medicare Learning Network! Not only does it lay out all of Medicare’s preventive services in a very easy to use format, it also indicates which of these services can be performed using telehealth services by placing a “T” next to the description of the service.

Many know the Medicare Annual Wellness Visit (“AWV”) can be performed via telehealth, but are you aware Medicare allows screening and counseling for patients with alcohol misuse to be performed via telemedicine? To bill for this service, ...

Since 2020, telehealth services have seen many changes, but there were some significant changes to telehealth in the Centers for Medicare and Medicaid Services (“CMS”) 2024 Physician Fee Schedule Final Rule. Below, we will discuss these changes in detail:

• CMS added health and wellness coaching to the services that can be provided via telehealth on a temporary basis.
• CMS is delaying the requirement for an in-person visit with the physician or practitioner within six months of initiating mental health telehealth services.
• CMS is extending the current flexibility for periodic assessments for Opioid Treatment Programs (“OPT”) to be furnished via ...

Introduction

On April 10, 2024, The Centers for Medicare and Medicaid Services (CMS) released the proposed Inpatient Prospective Payment System (IPPS) for Fiscal Year (FY) 2025. Within the release was the proposed mandatory Transforming Episode Accountability Model (TEAM). In this article we will break down the proposed rule set forth by the Center for Medicare and Medicaid Innovation (CMMI), which is a program that allows policymakers to establish and test new payment delivery and reimbursement models for both Medicare and Medicaid.

The new TEAM model would be based on five (5) 30-day surgical episodes. ...

Pharmaceutical, medical device, and biotechnology companies (collectively life sciences companies or “LSCs”) utilize outside ‘experts’ (“Healthcare Professionals” and “Key Opinion Leaders”, collectively “HCPs/KOLs”) to provide a wide variety of activities. HCPs/KOLs are often engaged by product marketing/sales groups known as “thought leader liaisons” or “TLLs”, and by medical affairs departments referred to as “medical science liaisons” or “MSLs”. These clinical experts are often critical to an LSC’s success. Some of the activities they perform include, speaking, product training, advisory board participation, strategic market planning, assistance with regulatory submissions, ensuring the effective utilization of products, and serving as scientific ...

On April 1, 2024, the Centers for Medicare and Medicaid Services (“CMS”) finalized their Calendar Year (CY) 2025 rates for Medicare Advantage (“MA”) and Part D prescription drug programs. With the conversion to version 28 from version 24, along with the statement that payments from the government to MA plans will “increase” by an average of 3.70% ($16 billion) over 2024 / 2025 years, what does this mean for value-based care in general?

With the federal government expecting to pay between $500-$600 billion dollars in MA payments to private health plans in CY 2025, it appears that ...

Every primary care physician (PCP) in the United States should be integrated into an accountable care model. The primary objective of accountable care models is to provide all participating healthcare providers with the necessary incentives and resources to deliver top-notch, coordinated, team-based care that prioritizes health promotion. By doing so, it aims to minimize fragmentation and reduce costs for individuals and the healthcare system as a whole.

The Center for Medicare and Medicaid Innovation (CMS Innovation Center or “Innovation Center”) is embarking on an ambitious new strategy aimed at achieving fair outcomes through the provision of high-quality, ...

Recently, we have been getting questions about the new Healthcare Common Procedural Coding System (“HCPCS”) code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition).

This code went into effect for The Centers for Medicare and Medicaid Services (“CMS”) on 1/1/2024.

As you can see from the description of the code, there is a lot to unpack ...