Primary Care Coding Alert

PFS proposal includes TCM, CCM, complex CCM overhaul and introduction of PCM.

On July 29, the Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule (PFS) Proposed Rule. It includes four big potential changes to the various types of care management: transitional (TCM), chronic (CCM), complex CCM, and a new type CMS is calling principal care management, or PCM.

Here’s your first look at what may be on the horizon. But remember, some or all of these proposals could change again when the Final Rule is released on or around November 1.

Change 1: Possible Unbundling of TCM Services

CMS is proposing removing restrictions on billing 99495 (Transitional care management services with … medical decision making of at least moderate complexity …) or 99496 (… medical decision making of high complexity …) with such services as international normalized ratio (INR) monitoring, end stage renal disease-related services, interpretation of physiological data, and complex CCM.

Experts see this move as both positive and negative. “Bundling the TCM codes restricted their use. This will hopefully expand utilization of TCM, which CMS observes is low compared to the number of Medicare beneficiaries with eligible discharges,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

But some believe the changes don’t go far enough. “TCM is cumbersome for physicians to manage if they are not part of an integrated system that allows for notification of discharge. I applaud CMS for being willing to evaluate these codes, but the binding elements of some codes still need to be addressed,” says Barbara Hays, CPC, CPCO, CPMA, CRC, CPC-I, CEMC, CFPC, AAPC Fellow, Senior Managing Consultant with  Soerries Coding and Billing Institute in Grain Valley, Missouri.

Change 2: Time Increment Revision for Staff Reporting CCM

CMS is also proposing to add two new temporary codes to replace 99490 (Chronic care management services, at least 20 minutes of clinical staff time …) for Medicare. You’d use GCCC1 (Chronic care management services, initial 20 minutes of clinical staff time …) to describe the first 20 minutes of CCM service in a calendar month, while subsequent CCM provided by clinical staff would be reported with GCCC2 (… each additional 20 minutes of clinical staff time … per calendar month …).

This “move to allow offices to be paid for CCM with add-on codes for time is very encouraging,” notes Hays, although CMS has not decided how often you would be able to report GCCC2 over a given duration and is looking for comments on the subject before finalizing the code. However, “determining if a non-Medicare payer is accepting which code or whether secondary claims need to be adjusted for whichever code that insurance is accepting may also be a logistical nightmare,” Hays adds.

Change 3: New Care Plan Components for Complex CCM

Currently, you report complex CCM services using 99487 (Complex chronic care management services… 60 minutes of clinical staff time…) and +99489 (… each additional 30 minutes of clinical staff time…).

Both codes feature two components: the “establishment or substantial revision of a comprehensive care plan” and “moderate or high complexity medical decision making.” However, CMS is proposing two more temporary codes, GCCC3 and GCCC4, in place of 99487 and +99489, respectively. If finalized, GCCC3 and, by extension, its add-on GCCC4 will call for the establishment, implementation, revision, or monitoring of the comprehensive care plan instead of just the establishment or substantial revision.

Coding alert: CMS is also proposing changes in the language, and to the elements, of a typical comprehensive care plan such as the one currently found at  www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf.

The new element list, like the current one, will not be a requirement but a suggestion for CCM. However, the proposed list “provides a clear-cut picture of what must be included and eliminates the subjectivity of the topic. This will make care delivery more effective for the team and coordinating caregivers,” Hays believes.

Change 4: New PCM Services on the Table

“CCM, among other requirements, requires 2 or more chronic conditions. With the introduction of PCM, CMS is proposing to expand care management for patients with one high-risk condition,” explains Falbo.

To do this, CMS is proposing two more temporary codes: GPPP1 (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month …) and GPPP2 (Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month …).

The move is seen as a welcome change by many. “With estimates for the growth of chronic illnesses continuing to increase, and with spending on these conditions growing proportionately, these proposals, especially the addition of PCM, are movements in the right direction,” Falbo concludes.

To view a pdf of the unpublished draft of the proposed PFS, go to s3.amazonaws.com/public-inspection.federalregister.gov/2019-16041.pdf. The published version was not available at the time this newsletter went to press.

To comment on the proposal electronically, go to www.regulations.gov and submit your opinions no later than 5 p.m. on September 27, 2019.