Medicare Compliance & Reimbursement

Chronic care management gains big victory in new, reimbursable CPT code.

Get ready for both good news and bad news in Medicare’s final version of the 2015 Physician Fee Schedule (MPFS) rule.

Currently, Medicare providers are under a 0.5 percent payment update patch, thanks to the Protecting Access to Medicare Act of 2014 (PAMA), protecting them from the 2014 Physician Fee Schedule sustainable growth rate (SGR) cuts. PAMA will then enact a 0 percent update after the new year, through March of 2015.

The bad news: According to the 2015 MPFS, if Congress does not act before April 1, 2015, the SGR for Medicare payments will fall by 21.2 percent.

“We won’t know until we get closer to April, but it’s likely that Congress could just enact another patch at that time. That’s what they usually do,” says Karen Ferguson, senior director of public policy for the American Medical Group Association (AMGA). 

“Some people are pushing for SGR reform during the lame duck session in Congress, but I don’t think that’s as likely as a new payment patch this March,” Ferguson says.

Another change in the MPFS is continued development of the Physician Quality Reporting System (PQRS). For 2015, CMS requires that all professionals eligible for PQRS participation report at least nine quality measures and cover at least three National Quality Domains. Also, they must report each measure on a minimum of 50 percent of their patients to whom the measures apply. But despite the extra work, providers will not see a PQRS payment incentive for reporting in 2015, as they have seen in the past.

On a related note: CMS is also accelerating the implementation to the value modifier. “The quality portion of the value modifier will actually be calculated based on PQRS, and the agency has a statutory mandate to implement it to all physicians by 2017,” Ferguson says, “so they’re taking steps to do that in the final rule.”

The Bright Side: Approved Chronic Care Management Code

CMS has decided to reimburse non face-to-face chronic care management services — a big win for healthcare providers who’ve been performing these services for years without Medicare reimbursement. 

Providers will now be able to bill Medicare for these services via the new CPT® code 99490 — Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements

• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
  
• chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
  
• comprehensive care plan established, implemented, revised, or monitored.
  

Example: Non face-to-face care (following the above criteria) might be a nurse or care managers within the medical group following up with patients to make sure they are adhering to their programs, Ferguson says. 

“Originally, CMS had proposed a G-code, which would be unique to Medicare to fill in a gap to the existing CPT set, but they went ahead and adopted 99490,” Ferguson says.

Just make sure you have all your ducks in a row before you begin officially billing for chronic care management. “There are a lot of service elements to 99490; you need to have a lot of infrastructural elements in place to code it,” Ferguson says. For example, “you need 24/7 access to someone you can talk to for care management.” 

Adding this code for Medicare reimbursement “is a step in the right direction,” Ferguson applauds. “Many of our members, such as the larger, multi-specialty medical groups and other integrated healthcare delivery systems have done this kind of work for their Medicare patients without compensation, and many of them will meet the service elements because they have the infrastructure in place.” 

AMGA, however, has asked CMS to monitor this change closely to ensure it’s accomplishing what it was set out to do.