Medicare Reimbursement for Coordinating Care Across the Continuum: Keep Patients Healthy and Optimize Your Revenue Cycle

By Virginia Gleason, Sr. Manager, Advisory Services | Posted: 02/10/2020

Medicare Reimbursement

Medicare Reimbursement for Coordinating Care Across the Continuum: Keep Patients Healthy and Optimize Your Revenue Cycle

The Centers for Medicare and Medicaid Services (CMS) has established Medicare medical billing codes for services intended to keep patients healthy and better coordinate patient financial services to support patients in the community. These services include Transitional Care Management, Chronic Care Management and, new in 2020, Principal Care Management and are paid in addition to the physician’s E/M. In the November 1, 2019 release of the 2020 Medicare Physician Fee Schedule Final Rule (2020 Final Rule), CMS noted that only 9% of Medicare fee-for-service beneficiaries are presently receiving ambulatory care management services.1 In an attempt to expand access to health care management services, CMS made several changes intended to lessen the administrative burden on health care providers and further incentivize the provision of care management in the outpatient setting.

While CMS is lessening administrative burdens in an attempt to increase utilization of care management services, the Office of Inspector General issued a November 2019 report stating that Medicare’s care management payments “are at a higher risk for overpayment compared with payments for more established Medicare services.” The OIG found that “CMS did not have adequate controls in place, including claim system edits, to identify and prevent overpayments”. As part of CMS’ response to the OIG audit, CMS officials stated that they had developed potential CCM-specific claim system edits; but, “CMS has no current plans to implement them”. Given the lack of claim system edits and the risk for overpayment, the onus is on providers to establish strong internal processes that ensure billing compliance. Even with this onus on providers, the benefits of coordinating patient care across the continuum have shown that providers cannot afford to continue relying on a few office visits per year to improve patient outcomes and reduce costs; which are key components in the value-based reimbursement model which is a key component in Medicare’s Merit-Based Incentive Payment System for physicians.

Transitional Care Management (TCM)2

TCM services are intended to assist patients transition successfully from a hospital stay back to a community setting. According to CMS, a 2019 analysis of TCM services demonstrated reduced readmission rates, lower mortality rates and decreased healthcare costs for patients who receive TCM services. However, medical claims for TCM services are extremely low when compared to overall Medicare discharges. In 2018, Medicare reported only 13% of patients discharged from the hospital also had medical claims for TCM services. This means that either the transition of value-based care services are not being provided or the outpatient health care providers are not billing for these services. In an attempt to increase TCM utilization, CMS reduced some of the administrative burdens associated with billing TCM services, as part of the 2020 Final Rule. One such example is the elimination of the prohibition on billing certain health services furnished during the 30-day period covered by TCM. Notably, physicians can now bill for Chronic Care Management and Care Plan Oversight during the same period as TCM.

The goal of TCM is to avoid the patient being readmitted to a hospital. The key components include an interactive contact, certain non-face-to-face services and a face-to-face visit. TCM medical services may be furnished via telehealth, including the face-to-face visit. The American Academy of Family Practice has published checklists to assist with tracking and documentation of both the initial contact within two days of discharge and the face-to-face visit.3

Chronic Care Management (CCM)4

In 2015, Medicare began paying separately under the Physician Fee Schedule (PFS) for Chronic Care Management (CCM) (CPT 99490 or 99491). However, just as with TCM, CMS noted in the 2020 Final Rule that CCM “continue[s] to be underutilized”. CMS further notes that CCM is “increasing patient and practitioner satisfaction, saving costs and enabling solo practitioners to remain in independent practice” .5

Practitioners may bill for CCM services for a calendar month when at least 20 minutes of non-face-to-face clinical staff time, directed by a physician or other qualified health care professional, is spent on care coordination.6 CMS recognized CCM as a “critical component of primary care that contributes to better health and care for individuals”.7 CCM gives healthcare professionals the ability to be reimbursed for the time and resources used to manage complex patients between face-to-face appointments.

CCM services are non-face-to-face and provided to Medicare beneficiaries who have two or more chronic conditions expected to last at least 12 months, or until the death of the patient. Essentially, these services are for patients who are at significant risk of death, acute exacerbation/decompensation, or functional decline. CCM services can be provided not only at physician offices, but through Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Critical Access Hospitals (CAHs). Only one practitioner/facility per patient may be paid for CCM clinical services in any calendar month. The services may be furnished by the billing healthcare professional as well as clinical staff that meet Medicare’s Incident To rules.8 CMS anticipates “clinical staff will provide CCM services incident to the services of the billing physician” or non-physician practitioners. CMS references the CPT definition of “clinical staff”: “a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.”9

Principal Care Management

On November 12, 2019, CMS released the 2020 Medicare Physician Fee Schedule Final Rule (2020 Final Rule). The rule finalized two codes in a new category of clinical reimbursement for Principal Care Management (PCM) Services. PCM health care services were created to fill a gap left by CCM and provide an avenue for reimbursement of health care management services when managing a single chronic condition. Under the PCM codes, a specialist may now be reimbursed for providing patients with health care management that is more targeted within their particular area of specialty.

These new codes are effective January 1, 2020 and provide health care reimbursement solutions for managing one chronic condition. Many requirements are similar to those of CCM patient services, such as: an initiating face-to-face visit; patient consent; electronic care plan; and, home and community-based health care coordination. However, there are several key distinctions between CCM and PCM, in addition to the single chronic condition management. Most significantly, PCM services (G2064):

  • Must be furnished 30 minutes per month
  • Focus on the management of disease-specific care
  • Provided by Specialists vs. Primary Care Providers in most instances
  • Intended length of time is until the condition is stabilized

The second code for PCM services (G2065) allows reimbursement for at least 30 minutes of “clinical staff time directed by a physician or other qualified health professional”.

Of note, the PCM services are not limited to patients who have only one chronic condition. The PCM services are intended for specialists who manage one of a patient’s chronic conditions and allows multiple specialists to bill for PCM simultaneously (e.g. a cardiologist for arrhythmia and an endocrinologist for diabetes). While multiple specialists may bill for PCM services, PCM preferred services cannot be furnished or billed at the same time as:

  • Other health care management services by the same practitioner for the same patient; nor
  • Interprofessional consultations for the same condition by the same practitioner for the same patient.

In the 2020 Final Rule, CM stated it will consider adding PCM to HCPCS code G0511 which would allow FQHCs and RHCs to be reimbursed for PCM management services. However, at this time, it has not done so and the codes are not available to FQHCs and RHCs.

Medicare Reimbursement for Care Management

Medicare’s reimbursement for patient care management services has an overarching clinical goal: improving the health of Medicare patients with chronic medical conditions. A research study published in the Journal of General Internal Medicine10 found that CCM services reduced growth in total monthly expenditures per patient when patients received healthcare services more than once in that month. The report tracked costs for patients enrolled in CCM programs vs. costs for non-CCM patients. These results suggest that practices adopting CCM will score very well in the cost category of the Merit-based Incentive Payment System’s performance scores. This becomes vital as Medicare moves to merit-based reimbursement for physician services.

Increased health care revenue is only one part of the equation when considering the implementation of care management in physician practice operations. Most importantly, patients are less likely to be hospitalized or go to the emergency department when followed in an outpatient clinical care management program.11 With an effective care management program, physicians can maximize the care aspects during face-to-face visits while having a team that addresses needs and quality metrics outside of these visits.

Ready to learn more? Visit nthrive.com/contact-us/, click Sales Questions, complete the short form and we’ll be in touch soon.

1Physician Fee Schedule Final Rule; 84 FR 62568

2https://www.federalregister.gov/documents/2014/11/13/2014-26183/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory

3https://www.aafp.org/fpm/2013/0500/p12.html

4https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management

5Physician Fee Schedule Final Rule; 84 FR 62568

6Connected Care ToolKit: Chronic Care Management Resources for Health Care Professionals and Communities; https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/connected-hcptoolkit.pdf

7Id.

8https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf

9American Medical Association, 2018 CPT Handbook

10Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study; Journal of General Internal Medicine, vol. 32, issue 12, Dec 30, 2017.

11Making Sense of MACRA: Simplifying Chronic Care Management; American Academy of Family Physicians, Family Practice Management 2017 Jul-Aug; 24(4):33-35.; Utilize CCM Codes to Maximize Patient Care, Payment American Academy of Family Practice, November 30, 2018 AAFP News, https://www.aafp.org/news/practice-professional-issues/20181130ccmcoding.html