CMS Improves Care Management Reimbursement

• December 12, 2019
• Jennifer Boese

Improving care management got a boost in the final 2020 Physician Fee Schedule (PFS) rule. The Centers for Medicare & Medicaid Services (CMS) approved a package of coding and reimbursement changes intended to allow for more coordinated care and care management of patients with one or multiple chronic conditions.

Let’s take a look…

Transitional Care Management (TCM)

CMS made several improvements under TCM billing and reimbursements. CMS finalized an increased work RVU of 2.36 for CPT code 99495 and 3.10 for CPT code 99496. In addition, CMS finalized that 14 codes previously thought to have substantial overlap with TCM and, therefore, not billable with TCM, may now be concurrently billed. Those codes include CPT and G codes related to end stage renal disease, prolonged services and complex Chronic Care Management (CCM) among others. CMS also added CCM codes, CPT codes 99490 and 99491, to the concurrent billing list.

Chronic Care Management (CCM)

Overall, CMS listened to and agreed with stakeholder feedback related to coding changes to improve payment accuracy for CCM – both complex CCM and non-complex CCM. CMS had originally proposed four new G codes for this purpose, but due to stakeholder feedback about the potential burden of the proposed new G codes and the ongoing work of the CPT Editorial Panel, CMS finalized only one of the four codes. CMS also relaxed the requirements of the comprehensive care plan.

• For non-complex CCM, CMS had proposed adopting two new G codes – GCCC1 and GCCC2 – to be used for PFS payment instead of CPT code 99490. CMS only finalized the add-on code, G2058, which can be billed with 99490. CMS placed a frequency limit of two on G2058.
• For complex CCM, CMS had proposed adopting two new G codes — GCCC3 and GCCC4 — to be used for PFS payment instead of CPT codes 99487 and 99489. CMS did not finalize either code. Instead, CMS finalized that for CY 2020 it will continue to recognize CPT codes 99487 and 99489, but with a different care planning element for purposes of billing Medicare. Beginning in CY 2020, for PFS billing purposes for CPT codes 99487 and 99489, CMS interprets the code descriptor “establishment or substantial revision of a comprehensive care plan” to mean that a comprehensive care plan is established, implemented, revised, or monitored.
• In order to clarify its policy, CMS finalized the following new language for a comprehensive care plan: The comprehensive care plan for all health issues typically includes, but it not limited to, the following elements: problem list; expected outcome and prognosis; measurable treatment goals; cognitive and functional assessment; symptom management; planned interventions; medical management; environmental evaluation; caregiver assessment; interaction and coordination with outside resources and practitioners and providers; requirements for periodic review; and when applicable, revision of the care plan.

Principal Care Management (PCM)

In recognition that there is considerable time needed to manage one chronic condition (as opposed to multiple), CMS created a new PCM payment and coding structure.

CMS specifically allows PCM to be billed along with remote patient monitoring (RPM). For more details on RPM policies included in the 2020 PFS rule, see the HI² blog post on virtual/telehealth reimbursement changes.

The new codes are G2064 (for physicians) and G2065 (for clinical staff).

• G2064: CCM for a single high-risk disease, e.g. PCM, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities. CMS finalized a work RVU of 1.45.
• G2065: CCM for a single high-risk disease, e.g. PCM, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities. CMS finalized a work RVU of 0.61.

In addition, specialists are able to use PCM codes as they stabilize complex patients in order to transition them back to their primary care physician. CMS also added a requirement that ongoing communication and care coordination between all practitioners furnishing care to the beneficiary must be documented by the practitioner billing for PCM in the patient’s medical record.

With the growing number of individuals with chronic conditions and in need of well-managed and coordinated care, the 2020 PFS final rule provides a suite of positive improvements. Please reach out with questions.

Tags: #caremanagement, #CCM, #clapromise, #createopportunities, #PCM, #RPM, #TCM, Health Care General, Health Care Policy, Payment Models/Reimbursement, Regulations | Comments Off on CMS Improves Care Management Reimbursement