Revenue Cycle Management Blog | GroupOne Health Source

Medicare Policy Changes in 2016: What You Need to Know

Written by Ricki Ransom | July 19, 2016

Recent changes to medicare policy will impact your practice and your patients. Here's what you need to know and how you can adjust to the new payment policies.

The Two-Midnight Rule

The changes to this rule came into effect in January this year. The Two Midnight Rule, founded in 2013, helps define inpatient versus out-patient stays, but does so in a way that can make patient intake awkward.

Patients staying in the hospital for "two midnights" must be assigned as "inpatients" and may not be placed under observation as out-patients. This includes patients admitted at 11:59 PM, where just 2 minutes later, they could be admitted as out-patients.

Under the new policy,  this rule is less strict, allowing for physician judgement to help make decisions on whether a patient is an inpatient or out-patient. As noted in the Centers for Medicaid and Medicare Services press release,

"This continues CMS' long-standing emphasis on the importance of a physician's medical judgment in meeting the needs of Medicare beneficiaries by providing clearer guidelines and a more collaborative approach to education and enforcement."

These decisions will be reviewed by Quality Improvement Organizations (QIO). Recovery Auditors will only hone in on hospitals with unusual high denial rates.

The American Hospital Association approved of the change, but asked that it be enforced on March 31, 2016, to give hospitals time to adjust to the new policy.

Medicare to Cover Advance Care Planning

For the first time Medicare will cover advance care planning for physicians to talk about end-of-life care and preferences with beneficiaries.

For the first time, and in-line with the recommendations of a wide range of stakeholders including bi-partisan members of Congress and the American Medical Association, Medicare will cover advance care planning for physicians to discuss end-of-life care and preferences with beneficiaries.

It used to be that billing for end-of-life planning was only available under the "Welcome to Medicare" visit, when, as the CMA rightly notes, a lot of patients would not need this planning.  

Expanded List of Reimbursable Telehealth Services

Yet another change to Medicare payment policy allows for an expanded list of reimbursable telehealth services which should increase opportunities to use the service as well as increase competition.

To receive Medicare, the telehealth service must be on the list of Medicare telehealth services and meet all of the following requirements:

  • The service must be furnished via an interactive telecommunications system.
  • The service must be furnished by a physician or other authorized practitioner.
  • The service must be furnished to an eligible telehealth individual.
  • The individual receiving the service must be on a telehealth originating site.

The new allowed services include the following:

  • 90963
  • 90964
  • 90965
  • 90966
  • 99356
  • 99357

While many have agreed that these new additions to telehealth are a step in the right direction, they have also warned that the codes are not easy to use. Doctors may be leaving quite a bit of money unbilled by not fully knowing how to apply the codes.

A good example of the difficulty in using the new codes lies in how the new codes for prolonged service need to be used. Both 99356 and 99357 cover patients in either inpatient or observation setting who need more unit or floor time. Fair enough. But this can only be used with inpatient and skilled nursing facility evaluation codes. As well, they need to work with codes that limit to one subsequent hospital visit via telehealth every three days. Not overly straight forward.   

The Center for Medicaid and Medicare Services has also added End Stage Renal Disease (ESRD) services 90963, 90964, 90965, and 90966. The codes are for ESRD related services for home dialysis per full month.

The huge change here is that, home-based treatment used to not be covered by telehealth. In this case, however, they note that because the parts of the service begin at an authorized site, they can be furnished via telehealth.

Have You Been Affected by These Policy Changes?

Keeping up with medicare and medicaid policy changes can be hard. Rules are being proposed and revised all the time, often in ways that need the practice to change their policies quickly. Have you been affected by these recent payment policy changes, and if so, how did you deal with the change? Let us know in the comments.