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

  • 90845: Psychoanalysis

  • 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

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