CMS considers codes for additional non-face-to-face services

Medicare is continuing to recognize the full breadth of primary care, and of complex chronic care management in particular, through the proposed addition of two codes for the non-face-to-face care that internists provide to their patients.

ACP has been working to develop billing codes that would allow reporting of non-face-to-face care, and the College also wants those codes to be recognized by payers. This follows the path that the Centers for Medicare and Medicaid Services (CMS) has set for other initiatives for primary care, such as the Medicare Shared Savings Program, the Pioneer ACO (accountable care organization) model, the Advance Payment ACO model, and the Primary Care Incentive Payment Program.

In the July 19 Federal Register (online) CMS proposes to add two codes to represent complex chronic care management, GXXX1 and GXXX2 (placeholder codes, potentially to be specified in a final rule), and to provide separate payment for these codes. The new proposal from CMS is an important and welcome step. It differs in detail from the existing Current Procedural Terminology (CPT) codes for complex chronic care management (99487-99489) but is similar overall.

ACP notes that CMS avoids making the complex chronic care management proposal specialty-specific and instead chooses to focus on a practice's ability to provide the required services. The College will review the details of this proposal, along with the other sections of the proposed rule, in coming days and weeks. ACP's comments to CMS, as part of the rulemaking process, will be based on assessments from the College's committee members and staff experts.

CMS defines complex chronic care management services as those furnished to a patient with multiple (two or more) complex chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. The proposed codes are defined as follows:

• GXXX1, initial services; one or more hours; initial 90 days
• GXXX2, subsequent services; one or more hours; subsequent 90 days

Note that there is no proposed requirement for a face-to-face visit for either GXXX1 or GXXX2. CMS also proposes that there be either a Welcome to Medicare visit, also known as the Initial Preventive Physical Exam, defined by Healthcare Common Procedure Coding System (HCPCS) G0402, or an Annual Wellness Visit (HCPCS G0438 or G0439) in the 12 months prior to receiving complex chronic care management services. The Initial Preventive Physical Exam or Annual Wellness Visit would be used to determine who is the primary care clinician.

Because CMS recognizes that these are complicated and far-reaching services, beyond any existing evaluation and management service, the proposal for coverage is stringent in regard to the requirements for the practice. ACP expects to work with CMS to assure that no unnecessary administrative burdens are placed on physicians and their practices.

CMS specifically cautions that not all physicians and qualified practitioners would be fully capable of meeting the practice requirements of the complex chronic care management codes without making additional investments in technology and staff training and in the development of and maintenance of systems and processes to furnish the services.

If the proposal is finalized, practices would need to do the following:

• Use a certified, practice-integrated electronic health record that meets current Department of Health and Human Services meaningful use standards.
• Employ at least one advanced practice nurse or physician assistant whose written job description includes the care of patients who require complex chronic care management.
• Be able to demonstrate the use of written protocols.
• Provide 24/7 access to address a patient's acute complex chronic care needs. The patient would be given a means to contact the practice's clinicians in a timely manner. Members of the complex chronic care team would have access to the patient's full electronic medical record, even when the office itself is closed.
• Provide continuity of care with a designated practitioner or member of the care team with whom the patient would be able to obtain successive routine appointments.

CMS also specifies what would be included in a 90-day period for complex chronic care management services:

• a systematic assessment of the patient's medical, functional, and psychosocial needs,
• system-based approaches to ensure timely receipt of all recommended preventive care services,
• medication reconciliation with review of adherence and potential interactions,
• oversight of patient self-management of medications,
• a comprehensive, patient-centered care plan written in consultation with the patient and with other key practitioners who are treating the patient, based on physical, mental, cognitive, psychosocial, functional and environmental assessment and reassessment and an inventory of resources and supports, assuring that the care provided is harmonized with the patient's wishes and values,
• management of care transitions within health care, including referrals to other clinicians, visits that follow an emergency department visit, and visits following discharge from hospitals and skilled nursing facilities,
• coordination with home- and community-based clinical services, and
• enhanced opportunities for the patient to communicate with the clinician, to include not only the telephone but also secure messaging, Internet communication or other same-time consultation methods.

Despite rumors that CMS might propose or consider allowing patient-centered medical homes that are accredited or recognized by a private-sector accreditation group to be recognized as having met the practice requirements to bill for the new codes, the agency did not include this in the proposal.

Instead, the agency noted that national organizations use different approaches to formally recognize medical homes and stated that “therefore, we seek comment on these and other potential care coordination standards, and the potential for CMS recognizing a formal patient-centered medical home designation as one means for a practice to demonstrate it has met any final care coordination standards for furnishing complex chronic care management services.” ACP will provide comment on this proposal.

CMS has said that the patient would need to be notified and informed of the scope of complex chronic care management services before a physician can bill for them. As evidence of the consent, the physician would note it in the patient's medical record and the patient would be given a copy (printed or electronic) of the plan. Consent would be reaffirmed at least once every 12 months. The patient would be able to revoke consent at any time.

ACP appreciates the inclusion of this proviso, since in the absence of a face-to-face visit, it alerts both the patient and the physician that the chronic complex care management service would be provided.

CMS proposes that the codes be considered for the 2015 calendar year, in order to give the agency sufficient time to develop and obtain public input on the care standards. Consequently, there are no proposed relative values for GXXX1 and GXXX2. ACP expects to work with the CMS to establish relative values that are appropriate.

Clinicians would bill just one unit of the complex chronic care management in a 90-day period; the billing would not occur prior to the 90th day. ACP will request that CMS clarify whether this is to be counted in business days or calendar days.

Additionally, the proposed complex chronic care management codes would not be billable in conjunction with the transitional care management codes (CPT 99495 and 99496), the home health care supervision code (HCPCS G0181), the hospice care supervision code (HCPCS G0182), or the codes for end-stage renal disease services (CPT 90951-90970).

If a face-to-face visit were to occur within the 90-day complex chronic care management reporting period, the face-to-face visit would be separately reportable; the appropriate GXXX1 or GXXX2 code would also be reported. These limitations are appropriate to avoid the billing of overlapping services.

ACP views this proposal as a positive development for internal medicine. It signifies the importance that the government places on primary care and cognitive services, and it is a representation of the gains that ACP advocacy can obtain.