Since 2013, the Centers for Medicare & Medicaid Services (CMS) has been expanding Medicare payments for care management services. This trend continues in the 2017 Medicare Physician Fee Schedule Proposed Rule. Specifically, CMS proposes the following:
- Simplify the chronic care management (CCM) billing rules.
- Pay for complex CCM.
- Pay for care plan development.
- Pay for non-face-to-face prolonged evaluation & management (E/M) services.
- Change the supervision requirements for CCM furnished by rural health clinics (RHCs) and federally qualified health centers (FQHCs).
Additionally, CMS now recognizes the additional work involved in providing care management for patients with behavioral health conditions, proposing a new set of codes for these services.
Despite CMS’ prior efforts, CCM services have been woefully underutilized. In 2015, only 275,000 Medicare beneficiaries received these services, just a small fraction of those who are eligible.
Now, with the proposed easing of the CCM billing rules and expanded payment for related care management services, physicians should reconsider incorporating a formal ambulatory care management program into their practices.
- CCM Simplification
According to a national provider survey, regulatory complexity has been the primary obstacle to CCM adoption. In response, CMS proposes several revisions to the billing rules, all of which make it easier to provide these services. (For a complete explanation of the current rules, please refer to PYA’s white paper, Providing and Billing Medicare for Chronic Care Management.)
- No required consent form. Current rule: A physician cannot bill for CCM unless and until the physician secures the beneficiary’s signature on a consent form, the contents of which are specified in the regulation. Proposed rule: A physician may simply document in the medical record that certain information regarding CCM was furnished to the patient.
- Initiating visit. Current Rule: CCM must be initiated by the billing physician during a face-to-face E/M visit (Levels 2-5 E/M visit, an annual wellness visit, or initial “Welcome to Medicare” visit). Proposed Rule: Such initiating visit is required only for new patients and patients not seen within the last twelve months.
- 24/7 access to care. Current Rule: The physician must provide the beneficiary with a means to make timely contact with healthcare practitioners in the practice who have access to the beneficiary’s electronic care plan. Proposed Rule: The requirement regarding access to the beneficiary’s care plan is eliminated.
- Management of care transitions. Current Rule: The physician must create and exchange with other providers involved in the beneficiary’s care a clinical summary formatted according to certified EHR technology. Proposed Rule: The continuity of care document does not have to be formatted in a specific manner.
- Sharing of care plan and clinical summaries. Current Rule: The physician must make the electronic care plan available (a) on a 24/7 basis to all practitioners within the practice whose time counts toward the time requirement, and (b) share care plan information electronically (by fax only in extenuating circumstances) as appropriate with other providers. Proposed Rule: The electronic care plan must be made available timely within and outside the billing practice as appropriate, and care plan information must be shared electronically (can include fax) within and outside the practice with those involved in the beneficiary’s care.
- Beneficiary receipt of care plan. Current Rule: The beneficiary must be provided with a written or electronic copy of the care plan. Proposed Rule: The specification of the format in which the care plan is to be provided is eliminated.
- Documentation. Current Rule: A physician must document (in a qualifying certified electronic health record) communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits. Proposed Rule: Such communications must be documented in the patient’s medical record, but not necessarily a qualifying certified electronic health record.
- Complex CCM
CMS proposes to make payment for complex CCM, CPT 99487. The billing rules for CCM (CPT 99490) and complex CCM are the same, except complex CCM requires 60 minutes of non-face-to-face care management services per month, as compared to 20 minutes for CCM. CMS also proposes an add-on code for complex CCM, CPT 99489, for each 30-minute increment that goes beyond the initial 60 minutes.
Here are the projected national payment rates for these three codes. Note the 3.7% increase in the CCM payment rate for 2017:
- Care Plan Development
Acknowledging complaints that the time spent developing the CCM-required care plan currently is not reimbursed, CMS proposes to pay physicians for care plan development under a new code, GPPP7. The agency proposes the following description for this code:
Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service.
This add-on code is to be listed separately in addition to the primary service and billed separately from monthly care management services. The projected payment rate for GPPP7 is $63.68 (non-facility) and $46.15 (facility).
- Non-Face-to-Face Prolonged E/M Services
CCM and Complex CCM reimburse providers for clinical staff time spent providing care management services, not time spent by physicians. Recognizing the additional resource costs involved in spending an extraordinary amount of time outside the office visit caring for an individual patient’s needs, CMS proposes to make payment under two codes:
CPT 99358 – Prolonged E/M service before and/or after direct patient care, first hour
CPT 99359 – Prolonged E/M service before and/or after direct patient care, each additional 30 minutes (listed separately in addition to CPT 99358)
In discussing these services, CMS warns the time counted for these codes must be beyond the usual service time for the primary or companion E/M code that is also billed; no time can be counted more than once toward the provision of CPT 99358, 99359, and any other service reimbursable under the Medicare Physician Fee Schedule. The projected payment rate for 99358 is $113.41 (facility and non-facility); for 99359, it is $54.38 (facility and non-facility).
- CCM Supervision for RHCs and FQHCs
For CCM services billed under the Medicare Physician Fee Schedule, the clinical staff providing the non-face-to-face care management services must be under the general supervision of a physician or non-physician practitioner. Thus, the clinical staff member does not have to be physically present in the same suite of offices when providing this service.
Currently, however, clinical staff providing these services for RCH and FQHC patients are subject to direct supervision, i.e., they must be physically present in the same suite of offices as a physician or non-physician practitioner who is available to provide assistance.
CMS now proposes to amend the regulations concerning RHCs and FQHCs, changing the direct supervision requirement to a general supervision requirement. This change will afford these rural and safety net providers greater flexibility in providing CCM services for their eligible patients.
Behavioral Health Integration
Broadly speaking, the term “behavioral health integration” (BHI) refers to discussions, information sharing, and planning between a primary care provider and a behavioral health specialist relating to the treatment and management of a patient with behavioral health conditions. One BHI model, the psychiatric Collaborative Care Model (CoCM), has been proven to improve patient outcomes.
CMS proposes to make separate payment for services using the CoCM beginning January 1, 2017, using three new G-codes, GPPP1, GPPP2, and GPPP3. These codes describe the requirements for initial and subsequent collaborative care management involving a behavioral healthcare manager working in consultation with a psychiatric consultant under the direction of the patient’s treating physician.
Additionally, CMS proposes a new code for care management services for behavioral health conditions. With the exception of the qualifying diagnosis, the billing requirements for GPPPX are the same as those for chronic care management. The proposed reimbursement for this code is approximately $3.00 more than the reimbursement for 99490. The differential is meant to cover the additional resources required to care for patients with behavioral health conditions.
Taken together, these proposed enhancements to Medicare reimbursement for ambulatory care management should give physician groups more reason to consider providing these services. In addition to generating immediate revenue, care management services engage patients, improve outcomes, and reduce overall total cost of care. Thus, a care management program can serve as a bridge between today’s fee-for-service reimbursement and emerging value-based alternative payment models.
This opportunity is not limited to primary care physicians. Specialists who provide care for patients with chronic conditions can customize care management programs to meet patients’ specific needs. For example, an oncology practice can fund chemotherapy patient navigator services through care management revenue. Again, these services improve patient satisfaction and care coordination, thus improving quality and efficiency.
With a greater percentage of reimbursement tied to value each year, developing and deploying a care management infrastructure today will improve value-based performance in the near future. Modest investments in necessary clinical staff and technology – either directly or through third-party contracts – are a wise move in a changing healthcare environment.