Centers for Medicare and Medicaid Services (CMS) has recently released the final ruling for this year’s Medicare physician fee schedule. These changes include some exciting new regulations and rules for chronic care management. One change will be new principal care management services, which will be provided by Rosetext. CMS has also overhauled evaluation and management (EM) services for transitional care, chronic care management, and principal care management. This will take effect January 1, 2020.
These exciting changes can be implemented or added on to already existing chronic care management services. The implementation of these new services has the potential to change the look and operation of a chronic care management program. It gives clinicians the freedom to add additional services for those who need a little less help. It also gives clinicians more options when categorizing chronic care and principal care management patients.
For instance, rather than looping all patients into one category, it gives clinicians options to separate them into programs that properly suit the patients’ individual needs. That translates to patients walking away with a better outlook of their own program. Patients will be cared for in a manner suitable to their needs in terms of time management and care management. This makes for a happier patient, which in turn makes for a smoother operating chronic care management program.
Because of new definitions for transitional care and chronic care management, implementing codes will be easier to operate. Clinicians will better understand what to do to meet the needs of the codes.
Let’s take a look at the changes CMS made for transitional care management, chronic care management, and principal care management. It’s also important to note that these changes have opened up a new service line for rural health clinics, providing the ability to better serve a broader range of people.
Transitional Care Management (TCM) , and Chronic Care Management (CCM) The 2020 MPFS include an increase in payment for TCM. It also creates a Medicare-specific code for additional time spent beyond the initial 20 minutes allowed in the current coding for CCM services.
Principal Care Management Services (PCM) – CMS is creating new coding in 2020 for PCM, which will pay clinicians for providing care management services for beneficiaries with a single serious, high risk condition. PCM services would be used when a serious condition is expected to last between three months and a year or until death. The patient could receive PCM services from more than one clinician.
As with TCM, CMS notes that CCM is “increasing patient and practitioner satisfaction, saving costs, and enabling solo practitioners to remain in independent practice.” I have to say though that TCM and CCM are regularly underutilized in a practitioner’s office, resulting in practitioners leaving money on the table due to not using these codes. CMS also recognized that codes were underutilized. To address this, CMS is creating an add-on code for non-complex CCM, HCPCS code G2058.
Effective January 1, 2020, a practitioner can bill CPT 99490 for the first 20 minutes of clinical staff time spent performing CCM activities in a given calendar month, and can bill G2058 for the second and third 20-minute increments. Payment for CPT 99490 is $42.23, while each add-on code (up to two) pays $37.89. Thus, total reimbursement for an hour or more of non-complex CCM services is $118.01.
CMS is making one minor revision to the list of items typically included in the required comprehensive care plan, replacing “community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identify the individuals responsible for each intervention” with this language: “interaction and coordination with outside resources and practitioners and providers.”
CMS is also revising the care planning element for complex CCM (CPT 99487 and 99489). CMS will now interpret 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.
PCM – Principal Care ManagementEffective January 1, CMS will reimburse for PCM furnished to beneficiaries with a single chronic condition. The following tables were provided by PYA to identify key differences between CCM and PCM services:
Due to concerns regarding paying for duplicate services, CMS includes two additional requirements for PCM: (1) the practitioner billing for PCM must document in the patient’s record ongoing communication and care coordination between all practitioners furnishing care to the beneficiary, and (2) the practitioner cannot bill for interprofessional consultations or other care management services (excluding remote patient monitoring for the same beneficiary for the same time period as PCM).
As with CCM, CMS will reimburse for PCM services furnished directly by a physician or non-physician practitioner (as opposed to clinical staff under general supervision) under HCPCS code G2064. Payment will be $78.68 for 30 minutes or more of care management services. Medicare projects had this change in coding in CCM would increase allowed charges for family physicians by 12% by 2021.
Finally, CMS declined to create an add-on code to reimburse for time spent beyond 30 minutes per month providing PCM. The agency noted it will monitor PCM utilization to determine whether such additional reimbursement is warranted.