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Tuesday Dec 16, 2014

AAFP's Advocacy Efforts Paved Way for New Care Management Code

Get to know these five digits – 99490 -- because they will be important to you and your practice and have the potential to be transformational to our health care system.

These five numbers are the new CPT code for the chronic care management service, which family physicians participating in Medicare will be entitled to bill for each eligible Medicare patient starting Jan. 1. This policy is a significant change in the Medicare physician fee schedule for family physicians and is reflective of years of advocacy work by the AAFP.  

Family physicians have long argued that the most valuable services they provide their patients occur outside of the traditional face-to-face office visit. The variation and volume of these services have increased significantly as patients, especially those with multiple chronic conditions, live longer, more active lives, requiring more consistent interactions with their physicians, many of which do not require a face-to-face encounter with the physician. This increase in patient interactions has been facilitated by advances in technology that allow for asynchronous communication and the rapid transmittal of information between physicians and care sites.

Family physicians and their practices have always been defined by continuous and comprehensive care. In recent years, a third “c” was added to the list -- connected. Today, the delivery of continuous, comprehensive, and connected care is what family medicine is all about.

Through the 1990s and early 2000s, care management fees were viewed negatively by payers at all levels -- including the federal government. The concept of paying physicians for services provided outside of the face-to-face encounter was deemed of limited value. The AAFP ferociously disagreed with this line of thinking and aggressively moved to educate public and private payers on the value of care management services and how these services were essential to improving quality and lowering long-term costs.  

As the health care system began to adopt advanced primary care delivery models, such as the patient-centered medical home, the value of care management became more apparent to those that previously viewed them with a degree of skepticism. Today, there is near consensus that care management by family physicians and primary care practices is essential to achieving higher quality care for patients. More importantly, there is consensus that these services must be paid.

In 2013, CMS first proposed paying for chronic care management services under the Medicare physician fee schedule. The inclusion of this new service in the fee schedule was largely a result of AAFP advocacy efforts.    

CMS, through rulemaking, has established that the Medicare allowance for the chronic care management (CCM) service provided to an eligible patient will be approximately $42 for a calendar month. The payment is subject to Medicare deductible and co-insurance policies. Physicians will be allowed to bill the CCM code for services provided to Medicare patients with multiple chronic conditions that are expected to last more than 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensations, or functional decline.

CMS is encouraging physicians to acutely focus on patients who have four or more chronic conditions but has established the eligibility criteria at two or more chronic conditions.

The AAFP has an excellent tool to assist with risk-stratified care management that will benefit you with the CCM code.

To receive the CCM payment, a family physician must collect a signed patient agreement, and the practice must provide at least 20 minutes of physician-directed, clinical staff time per month that aligns with eight performance elements:

  • access to care management services;
  • continuity of care;
  • care management for chronic conditions;
  • creation of a patient-centered care plan;
  • management of care transitions; 
  • coordination with home and community-based clinical service providers; 
  • enhanced communication with patients and care givers; and 
  • electronic capture and sharing of care plan information via a certified electronic health records system.

The AAFP has created a variety of resources aimed at assisting family physicians and their practices. I urge you to read “Chronic Care Management and Other New CPT Codes.” This article will appear in the January/February 2015 edition of Family Practice Management, but it already is available online.

The AAFP also has created a Frequently Asked Questions document about the CCM benefit, a sample patient agreement/contract, a Medicare chronic care management service log, and patient-centered care plan template. These four resources were created to assist family physicians in securing the CCM payments and are available on the AAFP website.

Finally, please join the AAFP for a free webinar,(www3.gotomeeting.com) “Getting Paid for Chronic Care Management Under Medicare in 2015,” on Jan. 27 at 1:30 p.m. Eastern.  

This is the final In the Trenches for 2014. Thank you for engaging with the AAFP on our advocacy efforts during the past year. Your views, opinions, and suggestions make us better and allow us to focus our advocacy resources on those items that have the greatest impact on you and your patients. The next edition will publish on Tuesday, Jan. 6. I wish you and your families a wonderful holiday season and a prosperous new year.

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.