Medicare recently (July 2019) proposed major improvements to Chronic Care Management (“CCM”) and other reimbursable programs, effective Jan. 2020 (source proposal). These changes have the potential to significantly improve practice revenue and patient health (plus lower systemic costs).

Below, we’ve outlined the most impactful reimbursement proposals primary care providers and practice leaders need to know about for 2020.

Check back here in November, when the Medicare proposals are finalized, for an update on what will be included in the final 2020 fee schedule!

Key proposals:

1. TCM (Transitional Care Management) fee increase
2. CCM
a. New code for each additional 20 minutes of care management beyond 20 minutes per month
b. Complex CCM removes requirement for ‘substantial care plan revision’
3. Remote Physiologic Monitoring (RPM) now allows remote/off-site care managers
4. New “Personalized Care Management” for patients with 1 ‘serious chronic condition’

1. TCM (Transitional Care Management) fee increase

TCM incentivizes physicians to follow-up with a patient post-hospital discharge to ensure the patient stays healthy/avoids re-hospitalization. There were nearly 1.3 million TCM claims in 2018, up from 300,000 in 2013, TCM’s first year. However, an analysis by Bindman and Cox found that utilization is still low compared to the number of Medicare eligible discharges. More importantly, the analysis found that beneficiaries who received TCM services demonstrated reduced readmission rates, lower mortality, and decreased health care costs.

To increase clinicians’ use of this valuable care program, Medicare is increasing reimbursements for the codes by as much as 12%:

• RVU for CPT 99495 increase to 2.36 (from 2.11)
• RVU for CPT 99496 increase to 3.1 (from 3.05)

2. Chronic Care Management (CCM)

In its recent proposal, Medicare references data showing costs savings and increased patient/provider satisfaction attributable to CCM. Medicare then proposes new codes and changes in the hopes of expanding the program.

a. Most significant is the proposed code “GCCC2” (0.54 RVU) which reimburses “each additional 20 minutes” of needed non-face-to-face follow-up care beyond the first 20 minutes per month. This will allow higher quality follow-ups with patients needing time-consuming care management. For example, CircleLink’s own RNs may spend over 60 minutes in a month coordinating care with a single patient where complex approvals and logistics may be needed, e.g., delivery of medical equipment like an oxygen tank. Other times, a medication reconciliation in addition to detailed patient education/follow-ups may exceed 20 minutes per month but are nonetheless necessary to improve patient health and compliance. This new code (GCCC2) will make sure practices are incentivized to give patients all the follow-up care they need, not just 20 minutes per month.

b. Separately, Complex CCM codes no longer require “substantial care plan revision”. This requirement limited care for many folks requiring 60+ minutes of care coordination where they may not be a ‘substantial care plan revision’ as defined by CMS. To prevent overuse, Medicare is keeping the “moderate or complex medical decision making” point in place.

3. Remote Physiologic Monitoring (RPM) would allow remote care managers

Remote Physiologic Monitoring (~$60-$120 per patient per month for monitoring+managing Blood Pressure/Blood Sugar and other vitals readings remotely) has been affected in 2 key ways. First, there’s a new add-on code (994X0, 0.5 RVUs) for an additional 20 minutes of clinical care management time relating to vitals monitoring, on top of the existing CPT99457 code for the first 20 minutes.

Second, the proposal puts both CPT99457 and this new add-on code under general supervision rather than direct supervision. This means that off-site care managers like CircleLink’s 100% RNs can provide the “Remote physiologic monitoring treatment management services”, whereas in 2019 the clinical staff providing services needs to be on-site in the same facility as the supervising provider/doctor.

4. New “Personalized Care Management” for patients with 1 ‘serious chronic condition’

Finally, a new “Personalized Care Management” code – GPPP2 – covers patients with a single serious chronic condition. This opens up PCM for those who don’t qualify for CCM’s stringent 2-condition requirement. However, it should be noted that this code requires 30 minutes of staff time while paying the same amount as CCM pays for 20 minutes.

GPPP2 will require 1 condition for which a patient has received care for 3-12 months, which puts patient at risk for hospitalization, or has resulted in a recent hospitalization. Insofar as we can say now, GPPP2 may be billed by a specialist in parallel with a Primary Care Provider doing CCM. Terms and payment amounts will be roughly the same as CCM (~$42 per patient per month), except that the proposed 2020 fees appear to require 30 minutes of clinical staff time instead of 20 minutes for CCM.

Is your practice prepared to take advantage of these adjustments to CCM, RPM and other care management programs? Are you already doing your best with existing CCM and BHI programs? CircleLink can help demystify the reimbursement process and assess whether your practice is a fit for increasing revenue and patient health through these reimbursable services.

To learn more, please drop us a line at sales@circlelinkhealth.com or call 917-999-6560.