Investing in Prevention
By Amy Lynn Sorrel Texas Medicine June 2013

TMA Releases New Quality Improvement Tool

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Quality Feature – June 2013

Tex Med. 2013;109(6):39-42.

By Amy Lynn Sorrel 
Associate Editor

Jason V. Terk, MD, knows that every physician who provides preventive services invests time, staff, resources, and equipment to achieve better clinical outcomes for patients. Having labored through those calculations in his pediatric practice at Cook Children's Physician Network in Keller, he also knows physicians could use a simple tool to help determine the potential clinical and financial benefits of the preventive services now recommended for patients.

There are dozens of these services, with many related billing codes, now that the Patient Protection and Affordable Care Act (PPACA) requires most private health insurance plans and Medicare to cover certain U.S. Preventive Services Task Force (USPSTF) services without patients sharing costs. The services are in four categories: evidence-based screenings, counseling, routine immunizations, and preventive services for women and children.

Some physicians may already perform those services for their patients but miss out on additional payment; others may not realize the range of preventive services that would benefit patients. Still others may be unsure of the fiscal sustainability of providing the services.

To help physicians make those assessments, the Texas Medical Association Council on Health Care Quality developed 36 interactive "prevention calculators" encompassing all of the billing codes associated with each USPSTF guideline. They help doctors compare payments from various payers for those services, Dr. Terk says, but quality improvement is at the heart of the effort.

Dr. Terk, chair of the TMA Council on Science and Public Health, was a consultant to the Council on Health Care Quality subcommittee that developed the calculators.

"Ultimately, these tools are about eliminating the money concern as a barrier to providing preventive care services. In the end, these tools are about better patient outcomes because more preventive care is executed according to the USPSTF guidelines."

A Simple Calculator

The Council on Health Care Quality developed 35 calculators covering each of the preventive services under PPACA. A "general prevention" calculator drawing on common codes across various conditions also is available. A grant from the TMF Health Quality Institute (the Centers for Medicare & Medicaid Services' quality improvement organization for Texas) funded the project.

There is a calculator for everything from obesity, cancer, and diabetes screenings for adults to depression and hearing loss interventions for children. TMA is working on similar tools to help doctors evaluate their participation in the Medicare Physician Quality Reporting System and the commercial Bridges to Excellence quality programs.

To develop the prevention calculators, TMA combed through the CPT manual to identify the billing codes connected to each USPSTF guideline, says TMA Clinical Advocacy Director Joseph Gave. He calls the calculators "one-stop shopping" in that they include the billing codes for related clinical services, durable medical equipment, and lab tests.

The Excel-based tools are free and downloadable from the TMA website. TMA will update the calculators annually through 2015, and practices should make sure they use the most current version for the corresponding billing year.

Each calculator is customizable so physicians can enter the amount they receive from insurers for each code listed. Medicare or Medicaid payment amounts already are included.

After choosing a calculator and inputting contract fees, physicians can then enter the number of patients receiving or eligible for those services over a period of time to calculate their return on investment.

TMA recognizes that providing these services may not be financially sustainable for all practices, Mr. Gave says. Still, the tool provides "a very practical look down to the nickels and pennies at how doctors stand to benefit from each guideline."

Mr. Gave warned that the calculators are for use only by individual practices. Federal and state antitrust laws prohibit physicians from sharing contracted payment information with other doctors and prevent TMA from collecting the data.

Fringe Benefits

Some homework is involved, but simply entering the fees for each service can be an eye-opener and can help physicians' negotiations with private health plans, says Keller family physician Gregory M. Fuller, MD, a member of the Council on Health Care Quality.

Getting familiar with the various codes can help physicians educate themselves and their patients about the prevention recommendations and perform the documentation needed to get paid.

For example, if a patient who smokes goes in for a hypertension check and has bronchitis, his or her physician can take the opportunity to discuss tobacco cessation, one of the guidelines.

Dr. Fuller's practice, North Hills Family Medicine, used its EMR system to identify more than 1,000 patients who could benefit from tobacco cessation counseling. "If we reach even 50 percent of them, that's additional revenue."

On the other hand, many primary care physicians are used to listing general evaluation and management (E&M) codes when they actually do much more.

"There are a lot of things physicians are doing without realizing they can get some additional payment," Dr. Fuller said. "If you are consulting with patients about their weight or about smoking cessation, there are additional codes you can use other than your E&M codes."

Instead of billing 99213 or 99214 for a visit that includes tobacco cessation counseling, he bills 99406 and receives an extra $13.10 per Medicare patient.

Using the prevention calculators, physicians can easily look at the codes to make sure they spend the required three to 10 minutes on tobacco counseling, for instance, to properly document and bill for the service.

That documentation, Dr. Fuller says, also can prove beneficial in other areas, such as certification for meaningful use of electronic health records or for status as a patient-centered medical home, and preparation for future value-based payment mechanisms.

But he cautions against "cherry-picking" patients based on how payers cover certain preventive services.

"If you are doing it for some patients, you should do it for everybody," Dr. Fuller said, not only because of the hassle of remembering each payer's fee structures, but also because patients and practices can only benefit.

The calculators may appear to be only for primary care physicians, but Dr. Fuller says prevention cuts across specialties.

"There is at least one thing in these tools that can help physicians no matter the specialty."

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Prevention Calculators  

TMA developed 36 interactive but simple calculators to help educate physicians on the requirements and billing codes associated with preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) and covered under the Patient Protection and Affordable Care Act (PPACA).

Some of the calculators for adults include screenings, counseling, and interventions for abdominal aortic aneurysm, breast and cervical cancer, breastfeeding, depression, type 2 diabetes mellitus, obesity, osteoporosis, sexually transmitted infections, and tobacco use.

Examples of calculators for child preventive services include major depressive disorder, hearing and vision loss, congenital hyperthyroidism, iron deficiency, obesity, and sickle cell disease.

Download the free calculators on the TMA website. Then follow a few easy steps to see the benefits of providing such care and evaluate the fiscal sustainability of offering these services. 

  1. Choose a calculator. Start with something that fits your practice and patient population.
  2. Enter the contracted fee amounts for each of the codes listed. Medicare and Medicaid payment rates, if applicable, are included.
  3. Enter the number of patients for whom you provide or could provide this treatment over a specific time period, such as one month. 

Details about the preventive services covered under PPACA are available on the USPSTF website

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Last Updated On

April 19, 2018

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