Principal Care Management (PCM) Services
2020 Medicare Physician Fee Schedule Final Rule (PCM Services Section)
A gap we identified in coding and payment for care management services is care management for patients with only one chronic condition. The current CCM codes require patients to have two or more chronic conditions. These codes are primarily billed by practitioners who are managing a patient’s total care over a month, including primary care practitioners and some specialists such as cardiologists or nephrologists. We have heard from a number of stakeholders, especially those in specialties that use the office/outpatient E/M code set to report the majority of their services, that there can be significant resources involved in care management for a single high risk disease or complex chronic condition that is not well accounted for in existing coding (FR 78 74415). This issue has also been raised by the stakeholder community in proposal submissions to the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which are available at https://aspe.hhs.gov/ptac-physician-focused payment-model-technical-advisory-committee. Therefore, we proposed separate coding and payment for Principal Care Management (PCM) services, which describe care management services for one serious chronic condition. A qualifying condition will typically be expected to last between 3 months and 1 year, or until the death of the patient, may have led to a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.
Although we did not propose any restrictions on the specialties that could bill for PCM, we expect that most of these services will be billed by specialists who are focused on managing patients with a single complex chronic condition requiring substantial care management. We expect that, in most instances, initiation of PCM will be triggered by an exacerbation of the patient’s complex chronic condition or recent hospitalization such that disease specific care management is warranted. We anticipate that in the majority of instances, PCM services will be billed when a single condition is of such complexity that it cannot be managed as effectively in the primary care setting, and instead requires management by another, more specialized, practitioner. For example, a typical patient may present to their primary care practitioner with an exacerbation of an existing chronic condition. Although the primary care practitioner may be able to provide care management services for this one complex chronic condition, it is also possible that the primary care practitioner and/or the patient could instead decide that another clinician should provide relevant care management services. In this case, the primary care practitioner will still oversee the overall care for the patient while the practitioner billing for PCM services will provide care management services for the specific complex chronic condition. The treating clinician may need to provide a disease specific care plan or may need to make frequent adjustments to the patient’s medication regimen. The expected outcome of PCM is for the patient’s condition to be stabilized by the treating clinician so that overall care management for the patient’s condition can be returned to the patient’s primary care practitioner. If the beneficiary only has one complex chronic condition that is overseen by the primary care practitioner, then the primary care practitioner will also be able to bill for PCM services. We proposed that PCM services include coordination of medical and/or psychosocial care related to the single complex chronic condition, provided by a physician or clinical staff under the direction of a physician or other qualified health care professional.
We anticipate that many patients will have more than one complex chronic condition. If a clinician is providing PCM services for one complex chronic condition, management of the patient’s other conditions will continue to be managed by the primary care practitioner while the patient is receiving PCM services for a single complex condition. It is also possible that the patient could receive PCM services from more than one clinician if the patient experiences an exacerbation of more than one complex chronic condition simultaneously.
For CY 2020, we proposed to make separate payment for PCM services via two new G codes: HCPCS code G2064 (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 with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities) and HCPCS code G2065 (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 with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities). HCPCS code G2064 would be reported when, during the calendar month, at least 30 minutes of physician or other qualified health care provider time is spent on comprehensive care management for a single high risk disease or complex chronic condition. HCPCS code G2065 would be reported when, during the calendar month, at least 30 minutes of clinical staff time is spent on comprehensive management for a single high risk disease or complex chronic condition.
For HCPCS code G2064, we proposed a crosswalk to the work value associated with CPT code 99217 (Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital ‘‘observation status’’ if the discharge is on other than the initial date of ‘‘observation status.’’ To report services to a patient designated as ‘‘observation status’’ or ‘‘inpatient status’’ and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234–99236 as appropriate])) as we believe these values most accurately reflect the resource costs associated when the billing practitioner performs PCM services. CPT code 99217 has the same intraservice time as HCPCS code G2064 and the physician work is of similar intensity. Therefore, we proposed a work RVU of 1.28 for HCPCS code G2064.
For HCPCS code G2065, we proposed a crosswalk to the work and PE inputs associated with CPT code 99490 (clinical staff non-complex CCM) as we believe these values reflect the resource costs associated with the clinician’s direction of clinical staff who are performing the PCM services, and the intraservice times and intensity of the work for the two codes will be the same. Therefore, we proposed a work RVU of 0.61 for HCPCS code G2065.
Although we proposed separate coding and payment for PCM services performed by clinical staff with the oversight of the billing professional and services furnished directly by the billing professional, we solicited comment on whether both codes are necessary to appropriately describe and bill for PCM services. We note that we are basing this coding structure on the codes for CCM services with CPT code 99491 reflecting care management by the billing professional and CPT code 99490 reflecting care management by clinical staff directed by a physician or other qualified health care professional.
We acknowledged that we concurrently proposed revisions for both complex and non-complex CCM services. Were we not to finalize the changes for both complex and noncomplex CCM services, we stated our belief that the overall structure and description of the CCM services remain close enough to serve as a model for the coding structure and description of services for the proposed PCM services. We solicited public comment on whether it would be appropriate to create an add-on code for additional time spent each month (similar to HCPCS code GCCC2 discussed above) when PCM services are furnished by clinical staff under the direction of the billing practitioner.
Comment: Most commenters supported separate payment for PCM services, noting the gap in payment for care management and coordination for a patient’s single complex or chronic condition. Other commenters were supportive of the policy goal but expressed concerns that the work described by PCM is duplicative of work being furnished as part of CCM and encouraged CMS to work with the CPT editorial panel to develop coding for this service.
Response: We appreciate the support for both the policy goal of appropriate payment for care management services conducted for a patient’s single complex or chronic condition and for separate payment for PCM services. We look forward to reviewing and considering recommendations from the CPT Editorial Panel and the RUC, should they develop and value CPT codes describing this or similar services, through our rulemaking process.
Comment: A few commenters stated that HCPCS code G2064 was undervalued and should have a work RVU of 1.45, which is the same work RVU as CPT code 99491 (Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, 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). CPT code 99491 describes the work associated with care management performed by the billing practitioner, in contrast to CPT code 99490, which describes the work associated with supervision of care management performed by clinical staff. Commenters pointed out that CPT codes 99491 and 99490 served as the model for HCPCS codes G2064 and G2065. Commenters stated that CPT code 99491 was a more accurate crosswalk for HCPCS code G2064 because both codes describe the work associated with care management and coordination performed by the billing practitioner, and G2065 describes the work associated with supervising care management done by clinical staff and was valued the same as CPT code 99490. Commenters also pointed out that, although PCM services describe care management associated with a single condition, the fact that this condition has most likely experienced an exacerbation or has caused the patient to recently be hospitalized, results in greater intensity than the work associated with managing multiple chronic conditions, some of which may be more stable.
Response: After considering these comments, we agree that the work RVU we proposed for code G2064 (1.28 RVUs) should be valued through a crosswalk to CPT code 99491, and we agree with the points made by commenters regarding the intensity of care management for a single condition, especially when that condition has likely experienced an exacerbation. We also agree that the relativity between CPT codes 99490 and 99491 should be preserved in HCPCS codes G2064 and G2065. Therefore, we are finalizing an RVU of 1.45 for HCPCS code G2064.
Comment: A few commenters supported creation of an add-on code for additional time spent engaged in PCM services beyond the initial 30 minutes, similar to HCPCS code G2060 discussed above.
Response: We thank commenters for their input. Given that this is a new service, we believe it would be more appropriate to monitor uptake and stakeholder response, and we will consider whether to establish a separate add-on code for additional time spent furnishing PCM services beyond the initial 30 minutes for possible future rulemaking.
Although we believe that PCM services describe a situation where a patient’s condition is severe enough to require care management for a single complex chronic condition beyond what is described by CCM or performed in the primary care setting, we are concerned that a possible unintended consequence of making separate payment for care management for a single chronic condition is that a patient with multiple chronic conditions could have their care managed by multiple practitioners, each only billing for PCM, which could potentially result in fragmented patient care, overlaps in services, and duplicative services. Although we did not propose additional requirements for the PCM services, we did consider alternatives such as requiring that the practitioner billing PCM must document ongoing communication with the patient’s primary care practitioner to demonstrate that there is continuity of care between the specialist and primary care settings, or requiring that the patient have had a face-to-face visit with the practitioner billing PCM within the prior 30 days to demonstrate that they have an ongoing relationship. We solicited comment on whether requirements such as these are necessary or appropriate, and whether there should be additional requirements to prevent potential care fragmentation or service duplication.
We received public comments on whether requirements such as these are necessary or appropriate, and whether there should be additional requirements to prevent potential care fragmentation or service duplication. The following is a summary of the comments we received and our responses.
Comment: Many commenters’ shared CMS’ concerns. Some commenters recommended that CMS not finalize separate payment for PCM services, stating that this would move away from patient-specific, continuous, comprehensive value based care management and coordination toward a more disease specific care management, resulting in fragmented care and service duplication. A few commenters with concerns about care fragmentation suggested that CMS first implement PCM through a demonstration. Others supported requiring the billing practitioner document ongoing communication and care coordination with any other practitioners overseeing care of the patient, such as primary care practitioners, pharmacists, hospitalists, or social workers, as applicable. These commenters stated that this would be sufficient to maintain coordination and continuity of care in the instance where multiple practitioners are involved in furnishing care to the beneficiary. A few commenters also suggested that CMS not allow billing of PCM services by multiple practitioners for the same indication. Still other commenters stated that it was not necessary to include any requirements pertaining to care fragmentation or service duplication, and that such requirements would be a barrier to uptake.
Response: While we share commenters’ concerns regarding care fragmentation and service duplication, we do not believe they rise to the level that separate payment should not be adopted for these services. The type of care management services that we believe are appropriately described by the PCM codes involve work intensively focused on managing a single condition and, with very few exceptions, could not be replaced by a single practitioner billing CCM services for management of multiple chronic conditions. However, we also believe it necessary to put in place some requirements so as to avoid a situation where each of a patient’s individual conditions are being managed separately by different practitioners who all bill for PCM services. Therefore, we are finalizing a requirement that ongoing communication and care coordination between all practitioners furnishing care to the beneficiary must be documented by the practitioner billing for PCM in the patient’s medical record.
Due to the similarity between the description of the PCM and CCM services, both of which involve non-face-to-face care management services, we proposed that the full CCM scope of service requirements apply to PCM, including documenting the patient’s verbal consent in the medical record. We solicited comment on whether there are required elements of CCM services that the public and stakeholders believe should not be applicable to PCM, and should be removed or altered.
A high level summary of these requirements is available in Table 23 and available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. Both the initiating visit and the patient’s verbal consent are necessary as not all patients who meet the criteria to receive separately billable PCM services may want to receive these services. The beneficiary should be educated as to what PCM services are and any cost sharing that may apply. Additionally, as practitioners have informed us that beneficiary cost sharing is a significant barrier to provision of other care management services, we solicited comment on how best to educate practitioners and beneficiaries on the benefits of PCM services.
We received public comments on whether there are required elements of CCM services that the public and stakeholders believe should not be applicable to PCM, and should be removed or altered. The following is a summary of the comments we received and our responses.
Comment: Most commenters supported application of the required elements of CCM to PCM with a number of refinements, although a few urged CMS not to add overly burdensome billing requirements. Commenters requested that CMS clarify that elements of CCM, such as the ‘‘systematic needs assessment,’’ ‘‘receipt of preventive services,’’ and a ‘‘comprehensive care plan’’ must be furnished only for the specific chronic condition for which the billing practitioner is treating the patient. Some commenters pointed out that a ‘‘comprehensive care plan’’ was not needed when a practitioner is engaged in care management and coordination of a single complex or chronic condition, and instead suggested it be changed to ‘‘disease specific care plan.’’ Other commenters suggest that we remove this language entirely. Commenters expressed concern with requiring that the EHR be certified to a particular standard. Commenters generally recommended that an initiating visit be furnished within a window of time to demonstrate that a relationship has been established between the beneficiary and the practitioner furnishing PCM.
Commenters supported the retention of the requirement that there be the capacity for in-person care management. Commenters also recommended that verbal and or written consent be documented in the medical record so that the patient is aware of the service and any applicable cost sharing, although some stated that this was a burdensome requirement given that they may not know in advance which beneficiaries will require PCM services.
Response: We thank commenters for all their input. We agree with commenters that a ‘‘disease-specific’’ care plan is more appropriate than a comprehensive care plan, as the practitioner will be providing care coordination and management for a single condition, and as such, the care plan may be more limited. We also agree that certain aspects of CCM, such as ‘‘systematic needs assessment’’ and ‘‘receipt of preventive services’’ should only be furnished as applicable to the condition being treated and should not be a requirement to bill for PCM services. Table 24 shows the elements of CCM, as revised in response to comments, that will be required for PCM.
Table 1. PCM Services Summary
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*All elements that are medically reasonable and necessary must be furnished during the month, but all elements do not necessarily apply every month. Consent only needs to be obtained once, initiating visits are only for new patients or patients not seen within a year prior to initiation of CCM.
With regard to the certified EHR, we continue to believe that use of certified EHR technology is vital to ensure that practitioners are capable of providing the full scope of PCM services, such as timely care coordination and continuity of care (see our prior discussion of this issue at 79 FR 67723). The use of certified EHR technology helps ensure that members of the care team have timely access to the patient’s most updated health information. Also, we believe that use of certified EHR technology among physicians and other practitioners will increase as we move forward to implement the Quality Payment Program, including MIPS and Advanced Alternative Payment Models, as well as other value-based payment initiatives. Accordingly, we are not modifying the proposed use of certified EHR technology as an element of PCM services.
We received public comments on how best to educate practitioners and beneficiaries on the benefits of PCM services. The following is a summary of the comments we received and our responses.
Comment: Commenters recommended that CMS issue guidance for billing and coding criteria, clinical situations in which PCM may be billed, and what defines a complex condition.
Response: We look forward to continued engagement with the public to revise and refine PCM services as they are implemented. We encourage stakeholders to submit questions and information to CMS so that we might consider changes or clarification for future rulemaking.
Additionally, we proposed to add HCPCS code G2065 to the list of designated care management services for which we allow general supervision as described in our regulation at § 410.26(b)(5).
Comment: Commenters supported adding HCPCS code G2065 to the list of designated care management services for which we allow general supervision.
Response: We thank commenters for their support and are finalizing as proposed.
Due to the potential for duplicative payment, we proposed that PCM could not be billed by the same practitioner for the same patient concurrent with certain other care management services, such as CCM, behavioral health integration services, and monthly capitated ESRD payments. We also proposed that PCM will not be billable by the same practitioner for the same patient during a surgical global period, as we believe those resource costs will already be included in the valuation of the global surgical code.
We also solicited comment on any potential for duplicative payment between the PCM services and other services, such as interprofessional consultation services (CPT codes 99446–99449 (Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional), CPT code 99451 (Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time), and CPT code 99452 (Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes) or remote patient monitoring (CPT code 99091 (Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days), CPT code 99453 (Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment), and CPT code 99457 (Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/ caregiver during the month).
Comment: Commenters generally supported restricting the number of care management services billable by the same practitioner for the same patient, stating that this was necessary to avoid service duplication. A few commenters also stated that services such as interprofessional consultation and chronic care RPM should not be separately billable in the same month as PCM by the same practitioner for the same beneficiary. Others disagreed, stating the RPM and interprofessional consultations describe distinct services not accounted for in the work of PCM. RPM in particular was described by these commenters as being complimentary to PCM services, rather than duplicative.
Commenters requested clarification as to potential overlap between PCM and CCM and some commenters suggested that PCM could be billed concurrent with CCM for the same beneficiary, if billed by different practitioners. Commenters also requested that CMS clarify any potential overlap between PCM and HCPCS code GPC1X (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).
Response: We do not believe there will be a duplication of care management between PCM and other care management services solely as a result of separate payment for the new PCM codes, particularly with the revised list of required elements which better distinguish PCM services from CCM. However, we also agree with commenters that PCM services should not be furnished with other care management services by the same practitioner for the same beneficiary, nor should PCM services be furnished at the same time as interprofessional consultations for the same condition by the same practitioner for the same patient. However, we are convinced by stakeholders who stated that RPM services are distinct from PCM and could be billed concurrently by the same practitioner for the same beneficiary provided that the time is not counted twice. We will also be monitoring billing of these services. We will appreciate continued input and engagement on these issues with the public and stakeholder community, and may make refinements to these policies in future rulemaking.
With regard to the relationship between PCM services and HCPCS code GPC1X, we do not believe there is any overlap. We note that PCM describes ongoing care management services and is billed monthly, whereas HCPCS code GPC1X is an adjustment to an office/ outpatient E/M visit (which are separately billable alongside PCM) to capture additional resource costs associated with performing either a primary care visit or a visit that is part of ongoing care of a patients single, serious, or complex condition. Comment: A commenter requested that RHCs and FQHCs be allowed to furnish and report PCM services.
Response: We thank the commenter for the suggestion. While we did not propose a new mechanism for RHCs and FQHCs to report PCM services specifically, we recognize that the requirements for the new PCM codes are similar to the requirements for the services described by HCPCS code G0511, which is the RHC/FQHC-specific general care management code, and will consider adding PCM to G0511 in future rulemaking.
Source: 2020 Physician Fee Schedule Final Rule. Federal Register. Vol. 84, No. 221. November 15, 2019 Rules and Regulations. Pages 125-129 (62692-62696)