Reimbursement for Chronic Pain Management in the 2023 Medicare Physician Fee Schedule: New Opportunities for Patients and Providers

As part of its ongoing effort to expand access to evidence-based treatments for acute and chronic pain and to improve the care experience for individuals suffering from pain, CMS introduced new CPT codes for Chronic Pain Management (“CPM”) services in the 2023 Medicare Physician Fee Schedule Final Rule (the “2023 MPFS”). 

The new CPM bundled payment covers integrated multimodal pain care that may include certain elements such as diagnosis, a person-centered plan of care, care coordination, medication management, and other aspects of pain care. These services will be available to patients who experience “persistent or recurrent pain lasting longer than 3 months.” 

The new codes give providers latitude to decide how the services will be administered based on individual patient needs.

Code Descriptors for the New Chronic Pain Management CPT Codes

HCPCS code G3002 (Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate. Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (When using G3002, 30 minutes must be met or exceeded.)) 

HCPCS code G3003 (Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month. (List separately in addition to code for G3002. When using G3003, 15 minutes must be met or exceeded.))

What Are the Requirements for Billing HCPCS Code G3002 and HCPCS Code G3003?

CPM services can be billed by a physician, nurse practitioner, physician assistant, or eligible qualified health care professional. However, the initial visit under HCPCS Code G3002 must be in person where both individuals are in a clinical setting such as a primary care practitioner’s office or another applicable setting. Patient consent for these services should be obtained and documented in the record.

While there are no delineated requirements for an established history or diagnosis of chronic pain, the patient must be experiencing persistent or recurrent pain lasting longer than 3 months. The determination of whether chronic pain exists and if CPM is merited is solely between the practitioner and the patient. 

While the code descriptors list elements of the care management bundle, CMS explicitly recognized that not all elements will be appropriate for every patient. Instead, using a person-centered approach, the clinician can optimize care according to individual circumstances and preferences. 

CMS acknowledged that a patient living with chronic pain might need to see more than one clinician type who is enabled to bill for the CPM services. A likely scenario might be a person who sees a primary care practitioner and a pain specialist. 

CMS noted that it is unlikely that a patient with pain would want or need to see more than two physicians or other qualified health professionals in the same month to manage their pain through CPM, but declined to restrict the number of clinicians who can bill the CPM codes at this time.

Are the Chronic Pain Management CPT codes “Telehealth services” or “Designated Care Management services”?

Interestingly, CMS added the CPM codes to the Medicare Telehealth list despite requiring the initial visit to take place in person at a clinic.

If Congress fails to enact new legislation expanding the availability of telehealth services to beneficiaries after the COVID Public Health Emergency, one may conclude that CPM services would be limited to patients in rural areas who would have to travel to an “originating site” such as a Rural Health Clinic to receive the services. 

CMS does specify, however, that many of the care management activities are commonly furnished remotely via telecommunications technology and may be done so after the initial in-person visit.

Unfortunately, CMS did NOT deem the new codes “Designated Care Management services,” meaning that clinical staff time may not be billed incident to a physician’s services under “general supervision,” where outsourced clinical staff is not in the same physical location as the physician. Instead, CMS said it may consider in the future which components could be performed by clinical staff and billed incident to the billing practitioner. 

Can the CPM codes be billed along with other care management codes like CCM or RPM?

Yes! CMS recognizes that HCPCS codes G3002 and G3003 are distinct from other care management services like Chronic Care Management, Principal Care Management, Remote Physiologic Monitoring, Remote Therapeutic Monitoring, and Behavioral Health Integration, and explicitly states that the CPM codes can be billed in the same month as other care management codes for the same patient. However, the same time may not be counted towards more than one code.

Key Takeaways: Chronic Pain Management codes

CMS took the initiative to create a new code set to reimburse for managing the care of chronic pain patients. This may be a good sign of things to come, as CMS recognizes the value of care management services for improving patient outcomes and reducing the overall cost of care. 

The new codes aren’t perfect; denying practices the ability to utilize outsourced clinical staff to support a CPM program will limit the adoption and overall success of these programs, and classifying CPM as telehealth services rather than designated care management services is questionable for the long term. 

But CMS has underscored its willingness to review and improve upon these and other care management code sets based on stakeholder feedback. Stakeholders should hold their feet to the fire!

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