Chronic Care Management and Behavioral Health Integration reflect CMS focus on coordinated, preventive care as part of the shift from volume to value
Last week, Nixon Law Group attended the Virginia Medical Group Management Association (VMGMA)‘s fall meeting in Williamsburg, and we were lucky enough to sit in on a session by the dynamic and talented Elizabeth Woodcock (of Woodcock & Associates). It was a whirlwind session on the key changes in the 2017 MPFS Proposed Rule, and we wanted to pass along all of the juicy details.
1. Rates, generally.
2017 rates will include a 2% reduction because of sequestration. It will also include a 0.51% negative adjustment offset by a 0.5% bump (net -0.01%). CMS proposes to reduce rates for Interventional Radiology, Pathology, and Vascular Surgery. CMS proposes a rate increase for Family Medicine, Allergy/Immunology, Endocrinology, Geriatrics, Geriatrics, HemOnc, Internal Medicine, Pediatrics, and Rheumatology. Radiology is taking a hit this year in more ways than one. The specialty will also see a 20% reduction in payment amounts for the technical component of imaging services that are X-rays taken using film.
2. Primary care and behavioral health clinicians are the winners this year. The MPFS has a series of new codes to support psychiatric collaborative care and behavioral health integration---the GPPP and GDDD series.
CMS is proposing a family of four temporary G-codes to facilitate separate payment for services covering behavioral health integration (BHI) in the primary care setting: GPPP1, GPPP2, GPPP3, GPPPX.
GPPP1: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional
GPPP2: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional
GPPP3: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional
GPPPX: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month.
3. CMS seems to have responded to the work of CPT and AMA regarding the true cost of services for those who are mobility- and cognitively-impaired.
CMS is proposing the below G-codes to (1) improve payment for cognition and functional assessment, and care planning for beneficiaries with cognitive impairment; (2) adjust payment for routine visits furnished to beneficiaries whose care requires additional resources due to their mobility-related disabilities; and (3) recognize for Medicare payment the additional CPT codes within the Chronic Care Management family (for Complex CCM services) and adjust payment for the visit during which CCM services are initiated (the initiating CCM visit) to reflect resources associated with the assessment for, and development of, a new care plan.
GPPP6: Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the physician or other qualified health care professional in office or other outpatient setting or home or domiciliary or rest home.
GDDD1: Resource-intensive services for patients for whom the use of specialized mobility-assistive technology (such as adjustable height chairs or tables, patient lifts, and adjustable padded leg supports) is medically necessary and used during the provision of an office/outpatient evaluation and management visit
4. In addition to the highly publicized chronic care management (CCM) code 99490, we may also see some new codes for transition care management, chronic care management and time spent with patients before and after direct care. This is a nod to the importance of care management in addition to care delivery.
Beginning in CY 2017, CMS proposes to recognize CPT codes 99358 and 99359 for separate payment under the PFS. These services are currently “bundled” under the PFS, but commenters to the 2016 rule stated that this does not reflect the time spent providing non-face-to-face care to patients outside of the office visit.
CPT code 99358 (Prolonged evaluation and management service before and/or after direct patient care, first hour); and
CPT code 99359 (Prolonged evaluation and management service before and/or after direct patient care, each additional 30 minutes (List separately in addition to code for prolonged service).
CMS is also proposing two additional complex chronic care codes. These codes can be billed for individuals with multiple chronic conditions that put patients at significant risk of death, decompensation, or functional decline.
CPT code 99487 (Complex chronic care without patient visit)
CPT code 99489 (Complex chronic care additional 30 min)
For the above codes, only general supervision is required, and it does not require that the clinician be face to face with the patient. In addition, it is unclear how the above codes will be delineated from the below code, which is related, but traditionally bundled with other codes. GPPP7 is meant to be direct pre- or post- care time.
GPPP7: Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service.
The CCM code 99490 will be worth $39.26 per month. In addition, CMS has made some changes related to necessary documentation, which should make billing this code easier for physicians.
5. If you are managing a diabetic population, CMS is proposing a Medicare Diabetes Prevention Program (MDPP), for which you can bill the below codes:
G0108: Diabetes outpatient self-management training services, individual, per 30 minutes
G0109: Diabetes outpatient self- management training services, group session [2 or more], per 30 minutes
6. The ICD-10 Grace Period will end October 1, 2016 and denials are expected to increase.
“As of October 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines,” CMS wrote in an ICD-10 FAQ updated in August. Specifically, Medicare review contractors will be able to reject billed claims based solely on specific ICD-10 diagnostic codes, while CMS no longer will authorize advance payments to providers whose claims under ICD-10 were being delayed.
7. Medicare is proposing an extended list of Medicare-reimbursable telehealth services. Here it is:
90791: Psych diagnostic evaluation
90792: Psych diag eval w/med srvcs
90832: Psytx pt&/family 30 minutes
90833: Psytx pt&/fam w/e&m 30 min
90834: Psytx pt&/family 45 minutes
90836: Psytx pt&/fam w/e&m 45 min
90837: Psytx pt&/family 60 minutes
90838: Psytx pt&/fam w/e&m 60 min
90846: Family psytx w/o patient
90847: Family psytx w/patient
90951: Esrd serv 4 visits p mo <2yr
90952: Esrd serv 2-3 vsts p mo <2yr
90954: Esrd serv 4 vsts p mo 2-11
90955: Esrd srv 2-3 vsts p mo 2-11
90957: Esrd srv 4 vsts p mo 12-19
90958: Esrd srv 2-3 vsts p mo 12-19
90960: Esrd srv 4 visits p mo 20+
90961: Esrd srv 2-3 vsts p mo 20+
90963: Esrd home pt serv p mo <2yrs
90964: Esrd home pt serv p mo 2-11
90965: Esrd home pt serv p mo 12-19
90966: Esrd home pt serv p mo 20+
90967: Esrd home pt serv p day <2
90978: Esrd home pt serv p day 2-11
90869: Esrd home pt serv p day 12-19
90970: Esrd home pt serv p day 20+
96116: Neurobehavioral status exam
96150: Assess hlth/behave init
96151: Assess hlth/behave subseq
96152: Intervene hlth/behave indiv
96153: Intervene hlth/behave group
96154: Interv hlth/behav fam w/pt
97802: Medical nutrition indiv in
97803: Med nutrition indiv subseq
97804: Medical nutrition group
99201: Office/outpatient visit new
99202: Office/outpatient visit new
99203: Office/outpatient visit new
99204: Office/outpatient visit new
99205: Office/outpatient visit new
99211: Office/outpatient visit est
99212: Office/outpatient visit est
99213: Office/outpatient visit est
99214: Office/outpatient visit est
99215: Office/outpatient visit est
99231: Subsequent hospital care
99232: Subsequent hospital care
99233: Subsequent hospital care
99307: Nursing fac care subseq
99308: Nursing fac care subseq
99309: Nursing fac care subseq
99310: Nursing fac care subseq
99354: Prolonged service office
99355: Prolonged service office
99356: Prolonged service inpatient
99357: Prolonged service inpatient
99406: Behav chng smoking 3-10 min
99407: Behav chng smoking > 10 min
99495: Trans care mgmt 14 day disch
99496: Trans care mgmt 7 day disch
99497: Advncd care plan 30 min
99498: Advncd are plan addl 30 min
G0108: Diab manage trnper indiv
G0109: Diab manage trn ind/group
G0270: Mnt subs tx for change dx
G0396: Alcohol/subs interv 15-30mn
G0397: Alcohol/subs interv >30 min
G0406: Inpt/tele follow up 15
G0407: Inpt/tele follow up 25
G0408: Inpt/tele follow up 35
G0420: Ed svc ckd ind per session
G0421: Ed svc ckd grp per session
G0425: Inpt/ed teleconsult30
G0426: Inpt/ed teleconsult50
G0427: Inpt/ed teleconsult70
G0436: Tobacco-use counsel 3-10 min
G0437: Tobacco-use counsel>10min
G0438: Ppps, initial visit
G0439: Ppps, subseq visit
G0442: Annual alcohol screen 15 min
G0443: Brief alcohol misuse counsel
G0444: Depression screen annual
G0445: High inten beh couns std 30m
G0446: Intens behave ther cardio dx
G0447: Behavior counsel obesity 15m
G0459: Telehealth inpt pharm mgmt
GTTT1: Telehealt con initial ccare
GTTT2: Telehealt con subseq ccare
We will be awaiting the final rule, and will update this blog with any pertinent changes. Until then, we encourage our clients to pay attention to the underlying message—value-based care, integrated care, and primary care will be the focus of CMS policy, and the rates indicate as much. If you’re interested in how you can transform your practice to prepare for the new shift to value, please reach out to Rebecca Gwilt at email@example.com.