Medicare proposes physician fee for complex chronic care management

Physicians who spend a lot of time treating patients with a host of chronic diseases may eventually be eligible for additional reimbursement under a new federal proposal.

On July 8, the Centers for Medicare & Medicaid Services (CMS) included in its proposed rule on the 2014 Medicare physician fee schedule a plan for a separate payment for complex chronic care (CCC) management services, beginning in 2015.

CMS says it believes the current evaluation and management (E/M) codes don't adequately over the resources required to furnish CCC management services to beneficiaries with multiple chronic conditions.

Building on its implementation of payment for transitional care management codes in 2013, CMS wants to establish a separate payment under the fee schedule for CCC management services. The patients would have to have  multiple complex chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

CMS does not spell out a lot of specifics related to this proposal, saying that it intends, through separate rule making, “to develop standards for furnishing complex chronic care management services to ensure that the physicians who bill for these services have the capability to provide them.”

But CMS says the following potential standards could be required:

•    The practice must use a certified electronic health record (EHR) for beneficiary care that meets the most recent standard for meaningful use. The EHR must be integrated into the practice to support access to care, care coordination, care management, and communication.

•    The practice must employ one or more advanced practice registered nurses or physicians assistants whose written job descriptions indicate that their job roles include and are appropriately scaled to meet the needs for beneficiaries who require CCC management services.

•    The practice must be able to demonstrate the use of written protocols by staff participating in the furnishing of such services, with further requirements.

•    All practitioners, including advanced practice registered nurses or physicians assistants, involved in the delivery of CCC management services must have access at the time of service to the beneficiary's EHR.

CMS proposes two separately payable CCC management services as G-codes, one for an initial service and the other for subsequent care after the initial service. CMS proposes to pay only one G-code per patient per 90 days but has not yet determined the payment amount. CMS indicates these codes will require at least 60 minutes of clinical time, and the 60 minutes must be personally performed or directed by the physician. CMS proposes that CCC management codes can be furnished “incident to” a physician's service under general physician supervision requirements when provided outside normal office hours.

Patients will be required to provide advance consent to the practice for the CCC management codes to be used, and this consent must be reaffirmed at least every 12 months. Patients can revoke consent at any time, and CMS includes details about patient handoffs in these situations. Also, patients must first receive an annual wellness visit  or initial preventative physical exam (i.e. “Welcome to Medicare Visit”) within the previous 12 months before a provider can bill a CCC management code.

The fact that CMS is potentially expanding payment for care management services and further recognizing the limitations of the existing E/M codes is good news. Of course, that good news is tempered by the reminder that, unless Congress intervenes in the interim, the conversion factor will drop 24.4 percent to $25.7109 in 2014, primarily as a result of the Sustainable Growth Rate.

CMS is accepting comments on the 2014 proposed rule, which includes recommendations on a host of other issues, until Sep. 6, 2013. If you don’t want to read the rule itself, you can always read the summary on the American Academy of Family Physician's web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians