Chronic care management: Medicare increases payment and relaxes standards

The Centers for Medicare & Medicaid Services (CMS) issued the 2017 Medicare Physician Fee Schedule Final Rule (the “MPFS Final Rule”) on Nov. 2, 2016, which implements payment policies designed to make it easier and more financially attractive for physician practices to furnish chronic care management (CCM) services to Medicare beneficiaries. The MPFS Final Rule also expands payment opportunities for behavioral health care services (see CMS Expands Medicare Payments for Behavioral Health Services), including new billing codes for practitioners who perform care management activities before or after furnishing direct patient care.

CCM background

Since January 2015, Medicare has been paying physicians, nurse practitioners, physician assistants, clinical nurse specialists, certified nurse midwives,[1] and their practice entities a chronic care management (CCM) monthly fee under CPT code 99490 to coordinate care for Medicare beneficiaries who have multiple chronic conditions.[2] However, the number of Medicare beneficiaries receiving CCM under 99490 has fallen far short of expectations. CMS has acknowledged complaints that CCM services are underpaid and subject to burdensome requirements that prevent physician practices from providing CCM services to Medicare beneficiaries who need these services. CMS has now responded by relaxing various service elements and billing requirements for CCM services and establishing new billing codes to incentivize practitioners.

Relaxation of service elements and billing Standards for CCM Code 99490

Thanks to the MPFS Final Rule, the CCM service elements and billing requirements will be relaxed starting January 1, 2017.  The principal revisions are summarized below:

CCM Code 99490 Current Requirements	CCM Code 99490 Revisions (2017)
Furnish a comprehensive evaluation and management (E/M) visit, annual wellness visit, or initial preventive physical examination and initiate the CCM service as part of this visit/exam	CCM initiating visit required only for new patients and patients who have not been seen within 12 months prior to commencement of CCM
Obtain signed beneficiary consent to receive CCM	Obtain written consent or document in the medical records that the required information was explained and whether the beneficiary accepted or declined the services.[3]  Existing written agreements are not affected by this change
Provide the beneficiary with a written or electronic copy of the care plan prior to initiating CCM	Provide a copy of the care plan to the patient or caregiver (prior requirement of written or electronic format has been removed)
Make care plan available electronically (not by fax) at all times (24/7) to anyone within the practice providing the CCM services, and share the care plan electronically (not by fax unless extenuating circumstances) outside the practice with other providers, as appropriate	Timely share care plan information electronically (including by fax), within and outside the practice with all individuals involved in the beneficiary’s care, as appropriate
Provide beneficiary 24/7 access to health care professionals who have access to the beneficiary’s electronic care plan within the practice to address urgent chronic care needs	Access to the electronic care plan will no longer be required outside of normal business hours
Standardized content for clinical summaries in accordance with certified EHR technology	Standards for clinical summaries (term to be revised to “continuity of care documents”) will be removed
Clinical summaries to be transmitted electronically (not by fax)	Can share continuity of care documents by fax
Beneficiary must provide authorization for electronic communication of his or her medical information with other treating providers	Authorization requirement removed
Use a qualifying certified EHR to document  (i) communication to and from home-based and community-based providers regarding the beneficiary’s psychosocial needs and functional deficits; and (ii) beneficiary consent and receipt of the care plan	EHR documentation requirement removed. Require documentation in the medical records of beneficiary consent and of communication with home-based and community-based providers regarding psychosocial needs and functional deficits

CMS warnings re: Lack of practitioner oversight or clinical integration

In the MPFS Final Rule, CMS noted that the billing practitioner is required to remain involved in the ongoing oversight, management, collaboration, and reassessment in connection with CCM.  CMS warned that the CCM service elements are deemed not furnished (and therefore, not billable as CCM) if there is little oversight by the billing practitioner or if there is a lack of clinical integration between the billing practitioner and any third party that provides outsourced CCM services.  CMS also stated its intent to monitor the impact of outsourcing on patient-centered care. 

Complex CCM services – New Medicare Codes 99487 and 99489

Under the new MPFS Final Rule, Medicare will pay physician practices for complex CCM services under two new CPT codes, 99487 and 99489. These codes will be available to practitioners beginning January 1, 2017. These complex CCM codes require the strict satisfaction of all CCM requirements under CPT code 99490, as well as the following additional elements:

1. Documented moderate or high complexity of medical decision-making; and

2. At least 60 minutes of clinical staff time per month (rather than 20 minutes for regular CCM services under 99490). 

Code 99489 is an add-on code for each additional 30 minutes of clinical staff time after the 60 minutes under 99487.

CCM initiating visit – New Medicare Code G0506

CMS is establishing a new add-on billing code, G0506, which provides an additional payment for extensive, outside the usual effort, face-to-face assessment and care planning by the billing practitioner (not clinical staff) during the initiating visit, annual wellness visit (AWV), or the initial preventive physical exam (IPPE).  This code can be billed in addition to the E/M, AWV, or IPPE code, but can only be billed once for a given beneficiary.

CMS clarified that G0506 cannot be billed by a single practitioner on the same day as G0505 (cognition and functional assessment) or as an add-on for the behavioral health integration (BHI) initiating visit or BHI services.[4]

Prolonged E/M services – Two new Medicare Codes 99358 and 99359

The MPFS Final Rule establishes new separate Medicare payment for non-face-to-face prolonged E/M services under existing CPT codes 99358 and 99359.  This payment is in addition to the payment under the underlying E/M code.  Code 99358 potentially applies when a practitioner personally spends at least an additional 60 minutes non-face-to-face time in performing the E/M service than the typical time, as assumed for purposes of Medicare Physician Fee Schedule (MPFS) rate-setting for the E/M code.[5] Code 99359 provides additional payment for 30 minute increments in excess of the first 60 minutes.

CMS will not allow CPT codes 99358 and 99359 to be reported during the same month as the complex CCM codes 99487 and/or 99489 or in the same 30-day period as the transitional care management (TCM) services code.  CPT codes 99358 and 99359 can be billed in the same month as regular (not complex) CCM codes, but neither can be reported as an add-on to a CCM initiating visit code G0506.

Conclusion

The new and revised Medicare payment policies for CCM, complex CCM, CCM initiating visits, and prolonged E/M services offer new sources of revenue for practitioners caring for Medicare beneficiaries suffering from chronic diseases, such as diabetes or heart diseases. However, practitioners  must establish appropriate policies and procedures to ensure that all requirements are satisfied and documented for billing and compliance purposes. 

To learn more about the MPFS Final Rule or the payment policies discussed above, contact Rick Hindmand or Isabelle Bibet-Kalinyak.