In November of 2019, the Centers for Medicare & Medicaid (CMS) rolled out the expansion of transitional care management (TCM), principal care management (PCM), chronic care management (CCM), remote physiologic monitoring (RPM), and other chronic care codes in their annual Physician Fee Schedule for 2020. In an excerpt from the report of the changes, CMS states:
“We believe gaps remain in coding and payment, such as for care management of patients having a single, serious, or complex chronic condition. In this final rule, we continue our ongoing work in this area through code set refinement related to TCM services and CCM services, in addition to new coding for principal care management (PCM) services, and addressing chronic care remote physiologic monitoring (RPM) services.”
I recently wrote about this expansion in Medical Economics, and I wanted to continue the conversation here on the Lightbeam blog. These opportunities bring greater efficiency to billing, reduce physician burden, and improve both quality and patient experience. Providers at any level can capitalize on their benefits. I want to provide an overview of the four primary chronic care code changes that care managers can utilize this year and into 2021.
Transitional Care Management Coding and Principal Care Management Improvements
Transitional care management is a form of care coordination that CMS finds to be underutilized, primarily because of the challenges that come with patient identification and timely outreach. Patients who do not receive transitional management are at risk for readmission, higher costs of care, and poorer outcomes.
With this expansion, CMS unbundled 14 codes, allowing TCM to be billed in the same calendar month as CCM, RPM, and other services like INR monitoring, ESRD, and Prolonged E/M services. TCM reimbursement has increased by 12% with the expansion, and patients will benefit from a timely follow up (one to two weeks post-acute) and continued chronic disease management without concern of gaps in care.
There are two new codes for principal care management (G2064 and G2065) that ensure clinicians are compensated for their care to patients with a single high-risk condition lasting three months or more. But, two requirements come with them: the billing provider must adequately document all communications and services with the patient, and they cannot bill for other consultations and care management services, except remote patient monitoring. These changes allow specialists to bill for high-risk care management and provide an opportunity for greater collaboration with a patient’s primary care physician.
Chronic Care Management
Chronic care management is also underutilized. Previously, practices were limited to only billing for 99490 or 99487, leaving a significant gap between the 20-60-minute mark. In response, the final rule ushered in G2058, which allows CCM providers to bill for each additional 20 minutes of clinical staff time by a qualified health care professional. The new G-code can be billed no more than twice a month alongside CPT 99490.
Remote Physiologic Monitoring
Remote physiologic monitoring before the latest final rule required patient monitoring under the “direct” supervision of the billing physician. With the 2020 update to coding, physicians are offered greater flexibility when utilizing RPM with a relaxed, “general” supervision ruling. Providers may now expand deployment of connected devices, allowing clinical staff and other qualified health professionals to monitor patients and mitigate exacerbations with timely intervention. The new ruling, combined with the RPM codes introduced in 2019 (the initial set-up, CPT 99453, devices, CPT 99454, and RPM, CPT 99457 and 99548), complements CCM services, as providers have visibility into biometric data trends that better inform complex care planning.
As with all policy changes, I am happy to provide a deeper dive into these coding opportunities and talk about other ways that clinical transformation can maximize care management for organizations. You can reach out to myself or another member of the team, or visit the Lightbeam Education Center for additional Thought Leadership content.
Alexis Edwards is a Clinical Transformation Advisor at Lightbeam.