Medicare Physician Fee Schedule proposals aim to increase utilization of care management services

CMS published the CY 2020 Medicare Physician Fee Schedule proposed rule on July 29, proposing to expand coding and payment options for transitional, chronic, and principal care management services. It also proposes to revise the language for the list of typical care plan elements for chronic care management.

CMS noted in the rule that while overall utilization of transitional care management (TCM) services has increased significantly since the first year of separate payments for these services in 2013, the overall utilization is low when compared to the number of beneficiaries with eligible discharges.

In an attempt to ease administrative burden and widen payment options for these services, CMS is proposing to remove billing restrictions on 14 HCPCS codes that had prevented them from being billed concurrently with TCM codes. These codes cover services such as prolonged services without direct patient contact, home and outpatient international normalized ratio (INR) monitoring, end-stage renal disease (ESRD) services, interpretation of physiological data, complex chronic care management services, and care plan oversight services. CMS had previously prevented concurrent billing of these codes with TCM codes out of a concern that the services overlapped each other, but after analysis, CMS believes these codes are complementary to rather than duplicative of TCM codes.

For chronic care management, CMS is proposing to expand reporting options by including new codes for non-complex and complex care management that define time for these services in 20-minute increments and allow additional payment for each additional 20 minutes spent performing these activities. CMS would implement this via HCPCS G-codes until the CPT Editorial Panel can consider and implement revisions to its current code set. CMS is seeking comment on whether using G-codes during a transitional period would be disruptive and whether there should be a limit on the number of times the 20-minute add-on code could be reported in a given service period.

CMS also noted in the rule that chronic care management codes do not account for care management services provided to a patient with only one chronic condition, and it said many stakeholders have commented to CMS that there can be significant resources involved in caring for patients with a single but serious chronic condition. Therefore, CMS is proposing to carve out coding and payment options for principal care management services, which are defined as care management services for one serious chronic condition. To qualify, the condition would be expected to last for at least three months, may have led to recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. CMS is not currently proposing restrictions on specialties that can bill for these services, but it said it expects most of these services would be billed by specialists rather than primary care practitioners. 

Finally, CMS is proposing new language for defining typical care plans for chronic care management by removing language the identifies who is responsible for interventions, as CMS said it can be difficult to maintain a listing of responsible individuals. The proposed language for a new definition of care plans would be:

The comprehensive care plan for all health issues typically includes, but is 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
• When applicable, revision of the care plan

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CMS published a fact sheet on the proposed rule on July 29 and has a call scheduled on August 12 to discuss the rule with the public. Comments are due to CMS no later than 5 p.m. on September 27.