Practice Management Alert

Question: There are multiple clinicians in my practice. Can the clinician who’s overseeing a patient’s care for a chronic condition use the codes describing principle care management (PCM)? Can multiple clinicians within our practice bill using this code? 

New Mexico Subscriber

Answer: Depending on the circumstances, the clinician overseeing the patient’s care may use the codes, but only one provider can bill for a specific condition, according to an update from the Centers for Medicare & Medicaid (CMS) fiscal year 2020 Medicare Physician Fee Schedule final rule.

Background: PCM describes care management services for one serious chronic condition, which you will be able to document using HCPCS codes G2064 (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management … physician or other qualified health care professional …) and G2065 (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management … physician or other qualified health care professional … clinical staff).

Experts have expressed mixed opinions regarding PCM. On the one hand, the code fills “an apparent gap in coding related to care management, in that the existing chronic care management codes require a patient to have two or more chronic conditions, and there is no code for chronic care management of the patient with a single condition,” observes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

However, “CMS should have either a definition of what a ‘high-risk disease’ truly is or a list so that practices would really understand when to use this type of code,” points out Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Further, “CMS would allow these codes to be reported for patients with multiple conditions when a particular physician was managing just one of them, which would move away from the continuous, comprehensive, and coordinated value-based care and primary care CMS has otherwise been encouraging as a cost-effective way to care for Medicaid patients,” believes Moore.

Plus: CMS is also going to unbundle transitional care management (TCM) services with a number of other services and add some minor changes to the chronic care management (CCM) guidelines.