Category I CPT Codes, requirements and basics and comparison vs Category III Codes

Category I CPT Codes

Category I CPT codes describe a procedure or service identified with a five-digit CPT code and descriptor nomenclature. The inclusion of a descriptor and its associated specific five-digit identifying code number in this category of CPT codes is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations.

In developing new and revised regular CPT codes the Advisory Committees and the Editorial Panel require:

•    that the service/procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;
•    that the suggested procedure/service is a distinct service performed by many physicians/practitioners across the United States;
•    that the clinical efficacy of the service/procedure is well established and documented in U.S. peer review literature;
•    that the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and
•    that the suggested service/procedure is not requested as a means to report extraordinary circumstances related to the performance of a procedure/service already having a specific CPT code.”




Requirement for Category I CPT Codes

All Category I codes have been reviewed by the American Medical Association’s Current Procedural Terminology (CPT) Editorial Panel and have met the following criteria:

• the service/procedure necessary for the procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;

• the suggested procedure/service is a distinct service performed by many physicians or other qualified health professionals across the United States;

• the suggested service/procedure and clinical efficacy of the service/procedure is well established and documented in peer review literature that meets the requirements set in the code change proposal form;

• the suggested service/procedure is performed with the frequency consistent with the intended clinical use;

• the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and

• the procedure or service is consistent with current medical practice.

Therefore, when a physician provides such a service or procedure and has documented his or her work properly and according to payer guidelines, the payer should not deny reimbursement for that service or procedure by claiming it is experimental or investigational.

Basic Code Sets
99201-99499 Evaluation and Management
00100-01999 Anesthesia
10021-69990 Surgery
70010-79999 Radiology
80047-89356 Pathology and Laboratory
90281-99607 Medicine


Modifiers usage on Category I CPT Codes


• Modifiers are used to “modify” the code that is chosen for a given procedure.

• These are listed in the front cover of the CPT book with a description

Example:
51 Multiple Procedure
52 Reduced Service


“Who maintains CPT?

The CPT Editorial Panel is responsible for maintaining the CPT code set. This panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. The Panel is comprised of 17 members. Of these, 11 are physicians nominated by the National Medical Specialty Societies and approved by the AMA Board of Trustees. One of the 11 is reserved for expertise in performance measurement.   One physician is nominated from each of the following: the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS). The remaining two seats on the CPT Editorial Panel are reserved for two members of the CPT Health Care Professionals Advisory Committee (one co-chair "full seat" and one "rotating seat" member at-large).”


Comparison: Category I Versus Category III Codes

Category III CPT codes are a set of temporary codes for emerging technology, services, and procedures. These codes are intended to be used to track the usage of these services, and the data collected may be used to substantiate widespread usage in the Food and Drug Administration (FDA) approval process. However, Category III codes are not given an automatic designation for services or procedures, as the CPT Editorial Panel determined that they did not meet the requirements for a Category I code.
Category I CPT codes are restricted to clinically recognized and generally accepted services, and not emerging technologies, services, and procedures. Category III CPT codes are not required to conform to the CPT Category I code requirements but instead are for reporting services or procedures that must have a relevance for research, either ongoing or planned, or the need to be tracked to evaluate the frequency of use.

Another important consideration in the development of Category III codes was the elimination of local codes under the Health Information Portability and Accountability Act (HIPAA). The local codes were temporary codes used by third-party payers as a mechanism to identify services and supplies such as services and procedures that had not yet been substantiated through research. Thus, Category III codes have, in part, taken the place of these local codes. As with Category I CPT codes, inclusion of a descriptor and its associated code number in CPT nomenclature does not represent endorsement by the AMA of any particular diagnostic or therapeutic procedure or service. Additionally, inclusion or exclusion of a procedure or service does not imply any health insurance coverage or reimbursement policy.

To expedite the availability of CPT Category III codes and to reflect the need to more quickly establish tracking mechanisms, the new CPT Category III codes are released semiannually via electronic distribution on the AMA CPT Web site (www.ama-assn.org/go/cpt ). The codes are effective six months after they are first posted. (Category III codes that are posted in July become effective the following January 1, and Category III codes that are posted in January become effective the following July 1.) The full set of Category III codes is then included in the next published edition of the CPT codebook for that CPT cycle. Such an early release is possible for Category III codes because the codes are not reviewed by the Relative Value Update Committee (RUC) for valuation by the Centers for Medicare and Medicaid Services (CMS). The AMA’s CPT Web site features updates of the CPT Editorial Panel actions and early release of the Category III codes on July 1 and January 1 in each CPT cycle

W series CPT code list

W series CPT codes Introduction


Current Procedural Terminology (CPT) codes are used for reporting medical services and procedures performed by physicians.  Their purpose is to provide a uniform language that will accurately describe medical, surgical, and diagnostic services, thereby providing an effective means for reliable nationwide communication among physicians, patients, and third parties.  This system of terminology is the most widely accepted nomenclature for the reporting of physician procedures and services under government and private health insurance programs.

CPT V. 6.0 provides the software to update the CPT files.  The software includes all CPT codes to code outpatient services for reimbursement and workload purposes (as determined by the American Medical Association) and the Common Procedure Coding System from the Health Care Financing Administration (HCPCS).  These codes may also be utilized to report inpatient services in certain instances.

In addition to the National CPT and HCPCS codes, the VA also uses the following VA specific HCPCS format codes.  These codes are not included in the HCPCS or CPT manuals.

W-CODES (VA NATIONAL CODES)



CPT Code Service Description Billing Unit Rate as of July 1, 2016 Max Daily Unit/ Service Limit Place of ServiceW5014 Art Therapy Individual - certified 45-50 min $63.43 1 11,99
W5026 Art Therapy Individual - certified 75-80 min $82.47 1 11,99
W5027 Art Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5028 Art Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5015 Art Therapy Group - certified 45-60 min $24.64 1 11,99
W5029 Art Therapy Group - certified 75-80 min $32.04 1 11,99
W5030 Art Therapy Group - licensed 45-60 min $27.74 1 11,99
W5031 Art Therapy Group - licensed 75-80 min $36.07 1 11,99
W5012 Dance Therapy Individual - certified 45-50 min $63.43 1 11,99
W5032 Dance Therapy Individual - certified 75-80 min $82.47 1 11,99
W5033 Dance Therapy Individual - licensed 45-60 min $69.78 1 11,99
W5034 Dance Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5013 Dance Therapy Group - certified 45-60 min $24.64 1 11,99
W5035 Dance Therapy Group - certified 75-80 min $32.04 1 11,99
W5036 Dance Therapy Group - licensed 45-60 min $27.74 1 11,99
W5037 Dance Therapy Group - licensed 75-80 min $36.07 1 11,99
W5010 Equine Assisted Therapy Individual -certified 45-50 min $63.43 1 99
W5044 Equine Assisted Therapy Individual -certified 75-80 min $82.47 1 99
W5045 Equine Assisted Therapy Individual - licensed 45-50 min $69.78 1 99
W5046 Equine Assisted Therapy Individual - licensed 75-80 min $91.41 1 99
W5011 Equine Assisted Therapy Group - certified 45-60 min $24.64 1 99
W5047 Equine Assisted Therapy Group - certified 75-80 min $32.04 1 99
W5048 Equine Assisted Therapy Group - licensed 45-60 min $27.74 1 99
W5049 Equine Assisted Therapy Group - licensed 75-80 min $36.07 1 99
W5020 Horticultural Therapy Individual - certified 45-50 min $63.43 1 99
W5050 Horticultural Therapy Individual - certified 75-80 min $82.47 1 99
W5051 Horticultural Therapy Individual - licensed 45-50 min $69.78 1 99
W5052 Horticultural Therapy Individual - licensed 75-80 min $91.41 1 99
W5021 Horticultural Therapy Group - certified 45-60 min $24.64 1 99
W5053 Horticultural Therapy Group - certified 75-80 min $32.04 1 99
W5054 Horticultural Therapy Group - licensed 45-60 min $27.74 1 99
W5055 Horticultural Therapy Group - licensed 75-80 min $36.07 1 99
W5022 Face to face caregiver peer to peer support 15 min $16.29 8/11 hrs per month 11,12,99
W5023 Collateral (telephonic) caregiver peer to
peer support
15 min $8.14 8/16 hrs per month 11,12,99
W5024 Mobile Crisis and Stabilization 15 min $26.13 12 hrs 12,99
W5025 Crisis Assessment 1 $313.54 1 12,99
W5016 Music Therapy Individual - certified 45-50 min $63.43 1 11,99
W5038 Music Therapy Individual - certified 75-80 min $82.47 1 11,99
W5039 Music Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5040 Music Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5017 Music Therapy Group - certified 45-60 min $24.64 1 11,99
W5041 Music Therapy Group - certified 75-80 min $32.04 1 11,99
W5042 Music Therapy Group - licensed 45-60 min $27.74 1 11,99
W5043 Music Therapy Group - licensed 75-80 min $36.07 1 11,99
W5018 Drama Therapy Individual - certified 45-50 min $63.43 1 11,99
W5056 Drama Therapy Individual - certified 75-80 min $82.47 1 11,99
W5057 Drama Therapy Individual - licensed 45-50 min $69.78 1 11,99
W5058 Drama Therapy Individual - licensed 75-80 min $91.41 1 11,99
W5019 Drama Therapy Group - certified 45-60 min $24.64 1 11,99
W5059 Drama Therapy Group - certified 75-80 min $32.04 1 11,99
W5060 Drama Therapy Group - licensed 45-60 min $27.74 1 11,99
W5061 Drama Therapy Group - licensed 75-80 min $36.07 1 11,99
W5000 Respite Care In Home/Commuinty Based 1 Hour $25.66 6/6 hrs per day 12,99
W5001 Respite Care Residential/Out of Home 1 overnight stayminimum of 12 hours $203.43 1/24 units per waiver year 12,99
W5062 Intensive In Home Services (EBP) Weekly $253.88 1 12
W5063 Intensive In Home Services weekly $201.42 1 12
W5066 Customized Goods and Services Billed Charges $2000.00 max 99

CPT CODE    DESCRIPTION


W0100    GENERAL MEDICAL EXAM, VA FACILITY
W0105    PSYCHIATRY EXAM, PER HOUR, VA FACILITY
W0110    NEUROLOGICAL EXAM, VA FACILITY
W0115    ENT EXAM, VA FACILITY
W0120    OPTHOMOLOGY EXAM, VA FACILITY
W0125    AUDIOLOGY EXAM, VA FACILITY
W0130    ORTHOPEDIC EXAM, VA FACILITY
W0135    CARDIOLOGY EXAM, VA FACILITY
W0140    DERMATOLOGY EXAM, VA FACILITY
W0145    NEUROSURGICAL EXAM, VA FACILITY
W0150    GU EXAM, VA FACILITY
W0155    GI EXAM, VA FACILITY
W0160    PULMONARY EXAM, VA FACILITY
W0200    POW EXAM, VA FACILITY, PER HOUR
W0210    AGENT ORANGE EXAM, VA FACILITY
W0220    SOCIAL/INDUSTRIAL SURVEY, PER HOUR
W0230    PTSD EXAM, VA FACILITY, PER HOUR
W5000    GENERAL MEDICAL EXAM, NON-VA FACILITY
W5010    PSYCHIATRIC EXAM, NON-VA FACILITY
W5015    NEUROLOGICAL EXAM, NON-VA FACILITY
W5020    ENT EXAM, NON-VA FACILITY
W5025    OPTHOMOLOGY EXAM, NON-VA FACILITY
W5030    AUDIOLOGY EXAM, NON-VA FACILITY
W5035    ORTHOPEDIC EXAM, NON-VA FACILITY
W5040    CARDIOLOGY EXAM, NON-VA FACILITY
W5045    DERMATOLOGY EXAM, NON-VA FACILITY
W5050    NEUROSURGICAL EXAM, NON-VA FACILITY
W5055    GU EXAM, NON-VA FACILITY
W5060    GI EXAM, NON-VA FACILITY
W5065    PULMONARY EXAM, NON-VA FACILITY
W5220    SOCIAL/INDUSTRIAL SURVEY, PER HOUR, NON-VA FACILITY
W5230    PTSD EXAM, NON-VA FACILITY

CPT CODE changes in 2019, add on code, deleted code

CPT Updates for 2019

The below CPT updates would give a brief note on 2019 code changes which includes the details on newly added codes, revised codes with descriptors and also the deleted codes. As we all know these codes are to be used for discharges occurring between Jan 1st,2019 through December 31st,2019.

There are no changes in the anesthesia and auditory system under surgery.

The chapters that saw the highest amount of changes are,

1. Category II codes,
2. Surgery – Integumentary,
3. Pathology
4. Medicine section.
A QUICK SNAPSHOT ON THE 2019 - CPT UPDATES
• 168 additions
• 72 deletions
• 49 revisions
With a Glimpse on the 2019 CPT updates related to some specialties which are high level overview of the changes in this newsletter


Add-on codes:


▪ 24 new add-on codes are added throughout the chapters

* Surgery Integumentary
* Surgery Musculoskeletal
* Surgery Cardiovascular
* Radiology
* Medicine
* Category II Code set


Cardiology:

▪ There are 16 CPT codes changes from cardiovascular.

* Loop recorder implantation and removal CPT codes are deleted (CPT 33282 & 33284)

* Leadless pacemaker, Cardiac rhythm monitor, peripherally inserted central venous catheter (PICC) are newly added in cardiovascular section.

* Peripherally inserted central venous catheter (PICC) CPT code are revised with added description of "without imaging guidance"


Musculoskeletal:

▪ There are 6 CPT codes changes from Musculoskeletal section.

* 3 codes added for Allograft (CPT 20932, 20933 & 20934)

* The existing knee arthrography contrast injection code 27370 was deleted and replaced with new CPT code 27369


Integumentary:


▪ There are 19 CPT codes changes from Integumentary.

* Fine needle aspiration, Tangential, Punch & Incisional biopsy codes are newly added in Integumentary section.

* 3 more deleted in skin biopsy & Fine needle aspiration codes from Integumentary.


Evaluation and Management:

▪ There are 10 CPT codes changes from Evaluation and Management.
* Interprofessional telephone/Internet/electronic health record assessment and management service, Remote monitoring of physiologic parameter codes are newly added in Evaluation and Management.

* CPT 99491 added in “Chronic Care Management CCM)’’ in E&M section.

*  The “electronic health record” are revised description in Interprofessional telephone/Internet/electronic health record assessment and management service.



Medicine:

▪ There are 60 CPT codes changes from Medicine section.

* Out of 29 new codes ranging from 1 new flu vaccine code are newly added to Electroretinography services, Developmental testing, Psychological and Neuropsychological testing evaluation services

* Pacemaker programming & Interrogation CPT code are revised with added description of " or leadless pacemaker system in one cardiac chamber"


* Loop recorder programming & Interrogation CPT code are revised with added description of " subcutaneous cardiac rhythm monitor system"

Radiology:


▪ 10 new codes were added as well as 6 deleted codes and 4 codes with revisions
o 76391: Magnetic resonance (e.g. vibration) elastography
o 76978, 76979, 76981, 76982 and 76983 – new ultrasound codes (please note that 76979 and 76983 are new add-on codes)
o 77046, 77047, 77048 and 77049 are all added codes for MRI of the breast



Deleted CPT codes


Deleted CPT Codes effective from 1/1/2019

10022 43760 64550 81213 96103 0189T 0363T 0372T 11100 46762 66220 81214 96111 0190T 0364T 0374T 11101 50395 76001 92275 96118 0195T 0365T 0387T 20005 61332 77058 95974 96119 0196T 0366T 0388T 27370 61480 77059 95975 96120 0337T 0367T 0389T 31595 61610 78270 95978 99090 0346T
0368T 0390T 33282 61612 78271 95979 0001M 0359T 0369T 0391T 33284 63615 78272 96101 0159T 0360T 0370T 0406T 41500 64508 81211 96102 0188T 0361T 0371T 0407T


Highlights of 2019 Changes


Eliminating the requirement to document the medical necessity of a home visit in lieu of an office visit

For E/M office/outpatient visits for new and established patients, allowing physicians to not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary

CMS will not apply the multiple procedure payment reduction policy to office visits and other services done at the same encounter

CMS will pay separately for two newly defined physicians’ services furnished using communication technology: Brief communication technology-based service & Remote evaluation of recorded video and/or images submitted by an established patient

CMS is removing the originating site geographic requirements and adds the home of an individual as a permissible originating site for telehealth services

CPT g9873, g9874, G9875, G9880- G9891 - DIABETES PREVENTION

Medicare Diabetes Prevention Program: New Covered Service

Medicare Diabetes Prevention Program (MDPP)

"HCPCS G-Code"    Description    "VM Allowed* "    Payment 


CORE SESSIONS  
      
G9873     MDPP beneficiary attended the first MDPP core session.    No    $25
G9874     MDPP beneficiary attended a total of 4 MDPP core sessions.    Yes    $50
G9875     MDPP beneficiary attended a total of 9 MDPP core sessions.    Yes    $90

CORE MAINTENANCE SESSIONS  
      
G9876    MDPP beneficiary attended 2 MDPP core maintenance sessions in months 7-9.    Yes    $15

G9877    MDPP beneficiary attended 2 MDPP core maintenance sessions in months 10-12    Yes    $15

G9878    "MDPP beneficiary attended 2 MDPP core maintenance sessions in months 7-9, and
the 5% weight loss from his/her baseline weight. Use G9878 or G9876."    Yes    $60

G9879    "MDPP beneficiary attended 2 MDPP core maintenance sessions in months 10-12, and
achieved the 5% weight loss from his/her baseline weight. Use G9879 or G9877"    Yes    $60


ONGOING MAINTENANCE SESSIONS          

G9882    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 13-15, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9883    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 16-18, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9884    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 19-21, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

G9885    "MDPP beneficiary attended 2 MDPP ongoing maintenance sessions in months 22-24, and
achieved the 5% weight loss from his/her baseline weight during the interval."    Yes    $50

ADDITIONAL CODES          

G9880    "MDPP beneficiary achieved at least 5% weight loss from his/her baseline weight in months 1–
12. This is a one-time payment available when a beneficiary first achieves at least 5% weight
loss from baseline as measured by an in-person weight measurement at a core session or
core maintenance session.
"    No    $160

G9881    "MDPP beneficiary achieved at least 9% weight loss from his/her baseline weight in months 1–
24. This is a one-time payment available when a beneficiary first achieves at least 9% weight
loss from baseline as measured by an in-person weight measurement at a core session, core
maintenance session, or ongoing maintenance session"    No    $25

G9890    "Bridge Payment: A one-time payment for the first MDPP core session, core maintenance
session, or ongoing maintenance session furnished by an MDPP supplier to an MDPP
beneficiary during months 1–24. This occurs when a beneficiary has previously received
his/her first core session from a different MDPP supplier. A supplier may only receive one
bridge payment per MDPP beneficiary."    Yes    $25

G9891    "MDPP session reported as a line item on a claim for MDPP services. This is a non-payable
code for reporting services of sessions furnished to MDPP beneficiaries (i.e. core sessions 2-3,
5-8, 10-16, and maintenance sessions before achievement of a performance goal)"    Yes    $0




This reference guide provides a snapshot of the MDPP payment structure and corresponding Healthcare Common Procedure Coding System (HCPCS) G-codes. This guide only applies to services furnished to beneficiaries receiving Medicare Part B coverage via Medicare Fee-for-Service (FFS).

A Glance at What is Covered

The first year of MDPP core services includes six months of weekly core sessions followed by six months of monthly maintenance sessions; the second year is contingent upon beneficiary performance and consists of monthly maintenance sessions

Follows a CDC-approved curriculum

• No beneficiary copay
• No referral required
• Beneficiaries are eligible for MDPP once-per-lifetime
* The ongoing maintenance sessions are unique to the MDPP services and not required for CDC recognition.

Beneficiary Eligibility Criteria

Specific criteria determine Medicare beneficiary eligibility throughout the MDPP services period Beneficiary Eligibility Requirements to Start Services:


Medicare beneficiaries are eligible for MDPP services if they meet the following criteria:

• Enrolled in Original Medicare (Part B) or Medicare Advantage (Part C)

• Body Mass Index (BMI) of at least 25 (23 if self-identified as Asian) on the date of the first core session

• Meet 1 of 3 blood test requirements within the 12 months prior to attending the first core session:

1. A hemoglobin A1c test with a value between 5.7% and 6.4%, or
2. A fasting plasma glucose of 110-125 mg/dL, or
3. A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)

• No previous diagnosis of diabetes prior to the date of the first core session (with exception of gestational diabetes)

• Do not have End-Stage Renal Disease (ESRD)

• Have not previously received MDPP services

Important Details on Eligibility Criteria

See the Beneficiary Eligibility Fact Sheet for more information
• Beneficiaries are only required to provide results from one of the 3 blood tests by the first core session
• The test must be completed in the 12 months before the first core session
• Beneficiaries may work with their health care provider to obtain the blood tests
• CMS does not designate specific types or forms of documentation that should be used as evidence of blood test results
• Beneficiaries’ weight and height must be measured in-person at the first core session and should be used to calculate BMI




Important Details on Eligibility Criteria

History of Diabetes
•Beneficiaries may self-report their history of type 1 or 2 diabetes
• If a beneficiary develops diabetes while receiving MDPP services, they can continue with the program
• History of gestational diabetes, which develops during pregnancy, does not disqualify a beneficiary from receiving MDPP services

MDPP Services
 • Beneficiaries are only eligible for services once-per-lifetime
• Beneficiaries who participated in any DPP services before April 1, 2018, or before they had Medicare coverage, are still eligible because these are not considered MDPP services
• Up to 2 years of services are covered for eligible beneficiaries at no copay
• No provider referral required

Using MDPP HCPCS G-Codes

• HCPCS G-codes are used when submitting claims to bill Medicare for payment. MDPP HCPCS G-codes may be used only one time per eligible beneficiary (except for G9890 and G9891)

• The initial session (G9873) or bridge payment (G9890) claim must be submitted before any other claims will be paid

• MDPP suppliers should submit claims when a performance goal is met

• Use the non-payable G-code (G9891) to report attendance at sessions that are not associated with a performance goal. These codes should be listed on the same claim as the payable code with which they are associated (e.g., report G9891 for sessions 2 and 3 if you are reporting G9874 for session 4 attendance)

• Each HCPCS G-code should be listed with the corresponding session date of service and rendering coach National Provider Identifier (NPI)

• If a beneficiary switches suppliers, the new supplier may receive a bridge payment (G9890) for the first MDPP session furnished to that beneficiary. More than one supplier may claim a bridge payment for the same beneficiary

• The Virtual Modifier, “VM”, should be appended to the end of any G-code that is associated with a session that was furnished as a virtual make-up session (e.g., G9891VM)


Skilled Nursing Facility Value-Based Purchasing Program

 The Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)

What is the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)?


The SNF VBP Program focuses on better outcomes and rewards skilled nursing facilities with incentive payments for the quality of care they give to people with Medicare, in particular reducing hospital readmissions. The SNF VBP Program moves CMS toward paying providers based on the quality, rather than the quantity, of care they give patients.

When will SNFs receive SNF VBP incentive payments?

SNFs will receive incentive payments, on an annual basis, at the start of each new fiscal year. The first time SNFs will receive incentive payments is on October 1, 2018, which is the start of fiscal year (FY) 2019. These incentive payment amounts are based on SNFs’ performance on the Program’s hospital readmissions measure during performance period, January 1, 2017, through December 31, 2017, and the baseline period, January 1, 2015 through December 31, 2015.

How will the program work?


A healthcare law called the 2014 Protecting Access to Medicare Act (PAMA) started the SNF VBP Program. Every year, CMS publishes a regulation that outlines what is required for the SNF VBP program. The most recent regulation can be found here. Under the SNF VBP Program:

SNFs will be evaluated on a hospital readmissions measure after a patient is discharged and has a hospital admission within 30 days.

SNFs will receive a performance score based on their individual performance and a performance score based on their comparison to other SNFs in the country.
SNFs will receive confidential quarterly and annual reports about their performance on the program’s measure.
SNFs will receive payment incentives based on their performance.
Since October 2016, CMS has been providing SNFs with quarterly confidential feedback reports containing information regarding their performance on the readmission measure specified for the SNF VBP Program. These quarterly reports are disseminated to SNFs via the Quality Improvement and Evaluation System (QIES)/Certification and Survey Provider Enhanced Reports (CASPER) system.

Public reporting of SNF performance will occur on the Nursing Home Compare website. In October 2017, performance data from the baseline year of the SNF VBP program was made available here. This includes SNFs’ performance on the Skilled Nursing Facility Readmission Measure (NQF# 2510) from Calendar Year (CY) 2015. Performance period data from CY 2017 will also be available on the Nursing Home Compare website. As a result of Phase Two review and corrections, an updated ranking file can be found here.

Performance data from the baseline year of the SNF VBP program are now available here. This includes SNFs’ performance on the Skilled Nursing Facility Readmission Measure (NQF# 2510) from Calendar Year (CY) 2015.

What types of SNFs are included in the SNF VBP Program?

All SNFs paid under the SNF Prospective Payment System (PPS) are included in the SNF VBP Program and are eligible for payment incentives based on their performance on the program’s measure. The types of SNFs in the Program include freestanding SNFs, SNFs associated with acute care facilities, and all non-critical access hospital (CAH) swing bed rural facilities.

What measures will be used in the SNF VBP Program?
Skilled Nursing Facility 30-Day All-Cause Readmission Measure

The Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) is used in the SNF VBP Program. The SNFRM estimates the risk-standardized rate of unplanned readmissions within 30 days for:

People with fee-for-service Medicare who were inpatients at PPS, critical access, or psychiatric hospitals.
Any cause or condition.
We finalized the SNFRM in the SNF PPS Final Rule for FY 2016. This fact sheet contains important information you should know about SNFRM.

This technical report and technical report supplement provide additional detail on the SNFRM.

Additional reliability testing for the SNFRM can be found in this memo.

What are the baseline and performance periods affecting FY 2019 payment for the SNF VBP Program?

For each year that the SNF VBP Program affects payment determination, SNFs are scored based on their performance during the applicable baseline period and performance period.

The baseline period affecting payment determination in FY 2019 is calendar year (CY) 2015 (January 1, 2015 through December 31, 2015).

The performance period affecting payment determination in FY 2019 is CY 2017 (January 1, 2017 through December 31, 2017).

How will SNFs' performance be scored under the SNF VBP Program?

SNFs will earn a SNF VBP Performance score (0 to 100) and ranking which is calculated based on that SNF’s performance on the measure specified for the Program during the performance period and the baseline period. The SNF VBP performance score is equal to the higher of the achievement score and improvement score.

SNFs will be awarded points for achievement on a 0-100-point scale and improvement on a 0-90-point scale, based on how their performance compares to national benchmarks and thresholds.
For more in-depth information on SNF VBP performance scoring, we refer you to the FY 2018 SNF PPS final rule and the FY 2019 SNF PPS final rule.

This report provides the analyses that were performed when proposing and finalizing the Program’s exchange function used to translate SNF performance scores into incentive payments.




**Please note that this mailbox is not secured to receive protected health information or patient-level data with direct identifiers.**


Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program: Frequently Asked Questions

What is the Skilled Nursing Facility Value-Based Purchasing Program?


The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program awards incentive payments to SNFs based on their performance on the Program’s measure of readmissions. SNF VBP payment incentives will be included on Medicare Part A claims paid under the SNF Prospective Payment System (PPS) as a single line item on each claim paid durinf the Fiscal Year (FY); no separate payment will be made. SNF VBP incentive payments do not any other type of claims (such as Medicare Advantage claims, Medicaid claims, or Medicaid managed claims). Beginning on October 1, 2018, which is the start of FY 2019, the Program will begin awarding incentive payments to SNFs based on performance on the SNF 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510).

What SNFs are included in the SNF VBP Program?
All SNFs paid under the SNF PPS will receive incentive payments under the SNF VBP Program as directed by the Social Security Act. The types of SNFs that are paid under the SNF PPS include freestanding SNFs, SNFs associated with acute care facilities, and all non-critical access hospital (CAH) swing bed rural facilities. The SNF VBP Program is not optional and does not require any action by SNFs to participate.

What measure is currently being used in the SNF VBP Program?


The SNF 30-Day All-Cause Readmission Measure (SNFRM) (NQF #2510) is the messure currently used in the Program. The SNFRM evaluates the risk-standardized rate of unplanned, all-cause inpatient hospital readmissions of Medicare beneficiaries. This measure assesses SNF patients hospital readmissions within 30 days of being discharged from a prior hospital stay.


What is the difference between a planned readmission and an unplanned readmission?
The SNFRM uses a readmission algorithm to identify planned readmisions. When the SNFRM measure was developed, a specific list of procedures or admitting diagnoses were identfied as being a planned readmission, based on input from technical experts. If a readmission does not meet the established criteria for a planned readmission according to this algorithm, it wil be considered an unplanned readmission. In addition, if a planned procedure occurs in combination with a diagnosis that disqualifies a readmission from being considered planned, the readmission with be considered unplanned.

When does the SNFRM 30-day readmissions period begin and end?
The SNFRM's 30-day readmission perion during which an unplanned readmission may be counted, referred to as the risk window, begins when a patient is discharged from an inpatient hospitalization and is subsequently admitted to a SNF within one day. The risk window ends 30 days from its start or when a patient is readmitted to a hospital, whichenve occurs first. For example, if a patient is discharged from a hospital to a SNF on 9/1/17, then readmitted to the hospital on 9/10/17, the 30-days risk window started on 9/1/17 and ended on 9/10/17 when the patient is readmitted to the hospital. A new 30-day risk window begin if the patient is subsequently discharged from the hospital and admitted back to the SNF.

Does the SNFRM count multiple hospital readmissions during a single 30-day readmission risk
window?


No. The SNFRM only assesses whether there is an unplanned readmission during a single 30-day readmission risk window. In the case of multiple readmissions, the 30-day risk window ends after the first readmission.

Are the measures in the SNF VBP Program the same as the measures in the SNF Quality Reporting Program (QRP) and on the Nursing Home Compare website?

No. The SNF VBP Program uses the SNFRM, which calculates the risk-standardized rate of unplanned, all-cause inpatient hospital readmissions within 30-days of a SNF patient’s discharge from a prior hospital stay. Congress directed CMS in statute to use the SNFRM in the SNF VBP program.

How are performance scores calculated?
SNF VBP performance scores are calculated by first inverting the risk-standardized readmission rate (RSRR), so that higher rates are equal to better performance. Next, the SNF’s RSRR is compared to the performance standards published in each final rule and awarded between 0 and 100 points. SNFs are scored on improvement, compared to their baseline performance
rate, and achievement, compared to the national performance rate during the baseline period. The higher of the improvement and achievement scores will be a SNF’s performance score.

Will SNFs be able to calculate their achievement and improvement points?
A SNF can calculate its achievement and improvement points using the formulas provided in
the FY 2017 final rule with the following data:
• The SNF’s performance period rate on the SNFRM
• The SNF’s baseline period rate on the SNFRM
• The applicable achievement threshold and benchmark for the Program year
The higher of a SNF’s achievement and improvement scores will equal their performance score.

How are incentive payments determined?


Each SNF’s incentive payment will depend on its performance score, which will be placed in the logistic exchange function to determine the corresponding incentive multiplier. The highest scoring facilities will receive the highest payment incentives, and the lowest scoring facilities will receive the lowest payment incentives, as required by statute. In 2017, CMS notified SNFs and stakeholders in the Federal Register via rulemaking that we would redistribute 60 percent of withheld funds to SNFs based on their performance score. After calculation of performance scores for all SNFs, the following steps will be used to calculate incentive payments:

1. Estimate the 60 percent of Medicare fee-for-service payments to SNFs to be redistributed to SNFs (the “incentive pool”).

2. Assign payment incentive multipliers to each SNF VBP Performance Score using the logistic exchange function so that the total amount of incentive payments matches the 60 percent incentive pool.

How will SNFs be notified of their performance in the Program?


CMS provides confidential feedback reports to SNFs on a quarterly and annual basis. Quarterly supplemental workbooks containing patient-level data are provided for quality improvement purposes. SNFs will also receive two annual reports; one report containing a full performance period and their measure score, and the second report containing the SNF performance score, rank, and payment incentive to be applied to Medicare claims in the upcoming fiscal year. SNFs can access all reports through Quality Improvement Evaluation System (QIES) Certification and Survey Provider Enhanced Reporting (CASPER) system.

What is Phase One of the Review and Corrections process?

Phase One is an opportunity for SNFs to review and submit corrections to the facility-level information that will be made publicly available. Requests will only be accepted until March 31 following delivery of the confidential report containing facility-level information and must be submitted to the SNFVBPinquiries@cms.hhs.gov mailbox. CMS will review the request and notify the SNF of any changes that may result.

SNFs will need the following information to submit a Phase One Review and Corrections request to the SNFVBPinquiries@cms.hhs.gov mailbox:

1. The SNF’s CMS Certification Number (CCN)
2. The SNF’s Name
3. The correction requested and the reason for requesting the correction. SNFs must also submit evidence, if available, supporting the request.

CMS advises SNFs not to send protected health information (PHI) or patient-level data with direct identifiers with review and corrections requests; the SNF VBP mailbox is not secured to receive this information. For specific questions, SNFs may use the identification number in their workbook as this is a randomly assigned number and not considered PHI.

How can I correct an error in my patient-level data?

If a SNF identifies an error in information not covered under Phase One or Phase Two of the SNF VBP Review and Corrections process, CMS advises SNFs to follow the established claims process to update the information or contact the readmitting hospital to make corrections.

CMS encourages SNFs to work with hospitals as a part of its care coordination efforts to make any corrections to claims information and submit to their Medicare Administrative Contractor (MAC) in a timely manner. If an error is identified that may result in a correction to SNF VBP measure rates, the SNF must demonstrate that claims have been corrected and reprocessed by the MAC in relevant fields impacting SNF VBP performance, prior to CMS considering recalculation of SNF VBP measure data before the Phase One Review and Corrections deadline.

What is Phase Two of the Review and Corrections process?

Phase Two is an opportunity for SNFs to review and submit correction requests to their performance scores and rank only, found in the annual performance score report. CMS will not consider any patient level information or RSRR measure rate correction requests during Phase Two of the Review and Corrections process, since these correction requests are classified as being out of scope for review. Phase Two requests will only be accepted for 30 calendar days following the annual performance score reports being made available. A SNF must submit correction requests to the SNFVBPinquiries@cms.hhs.gov mailbox. CMS will review the request and notify the SNF of any changes that may result.

SNFs will need the following information to submit a Phase Two Review and Corrections request to the SNFVBPinquiries@cms.hhs.gov mailbox:
1. The SNF’s CMS Certification Number (CCN)
2. The SNF’s Name
3. The correction requested and the reason for requesting the correction. SNFs must also submit evidence, if available, supporting the request.

CMS advises SNFs not to send protected health information or patient-level data with direct identifiers with review and corrections requests since the SNF VBP mailbox is not secured to receive this information.

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