CMS Adds Payment Boost for Primary Care Services - Expansion of Chronic Pain Management

Expansion of Chronic Care Management

The 2017 Medicare Physician Fee Schedule ("MPFS") Final Rule, issued November 2, 2016 by the Centers for Medicare and Medicaid Services ("CMS"), further recognizes the importance of primary care by establishing new payment methodologies for chronic care management and behavioral health services. In this issue of the HotStone, we will highlight how to navigate the changes.

I.  Chronic Care Management

Previously considered bundled into the payment for face-to-face Evaluation and Management ("E&M") services, in 2015 CMS implemented a Chronic Care Management ("CCM") CPT code:

99490 - "Medical practice and patient complexity required physicians, other practitioners and their clinical staff to spend increasing amounts of time and effort managing the care of comorbid beneficiaries outside of face-to-face E/M visits, for example complex and multidisciplinary care modalities that involve regular physician development and/or revision of care plans; subsequent report of patient status; review of laboratory and other studies; communication with other health care professionals not employed in the same practice who are involved in the patient's care; integration of new information into the care plan; and/or adjustments of medical therapy."

Despite CMS's intent to acknowledge and reimburse for the increased complexities primary care providers grapple with in managing chronically ill patients, CMS has found significant underutilization in the billing of CCM services since the inception in 2015. Smaller primary care practices in particular have had difficulty fulfilling the timing and documentation requirements due to limitations in their Electronic Health Record ("EHR"); older versions of which cannot support chronic care management. Primary care advocates hoped CCM would transform some practices by encouraging investment in infrastructure and adoption of team-based models of care. However, many primary care providers have forgone the opportunity due to both time and resources.

II.  Complex Chronic Care Management

CMS apparently listened! In the 2017 MPFS Final Rule, CMS acknowledged concerns that clinical time spent for CCM services regularly exceeded 20 minutes; emphasizing their goal "to pay as accurately as possible for services furnished to Medicare beneficiaries based on the relative resources required to furnish PFS services, including CCM services." CMS also sought to "reduce unnecessary administrative complexity," acknowledging the interoperability of certified EHR technology as a requisite for executing CCM service elements mandated by the 2015 PFS Final Rule. As a result of the feedback, CMS has integrated Complex Chronic Care Management ("CCCM") services CPT code 99487 and its add-on CPT 99489 into the 2017 MPFS as summarized below:

  • Complex chronic care management services, CPT 99487, requires the following elements:
    • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
    • Chronic conditions which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
    • Establishment of/or substantial revision of a comprehensive care plan;
    • Moderate or high complexity medical decision making;
    • 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
  • Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, CPT 99489:
    • List separately in addition to code for primary procedure.

III. Changes at a Glance

Below, we highlight the key changes to the core elements of CCM services, to include the new CCCM services. 

a)  Initiating Visit

Effective January 1, 2017, CMS will only require the CCM initiating visit for new patients, or patients not seen within the year. Repeal of the prior initiating visit requirement, as established by the 2015 MPFS Final Rule, will allow practitioners to report CCM services without requiring a potentially unnecessary E&M service.

b)  Beneficiary Consent

Stressing the importance of ensuring the beneficiary is informed and educated about CCM services, and is aware of applicable cost sharing, CMS has not removed the requisite for beneficiary consent. However, securing consent has been modified such that obtaining a written agreement is no longer a condition for payment.

Rather, the 2017 MPFS Final Rule advises "the practitioner could document in the beneficiary's medical record that this information was explained and note whether the beneficiary accepted or declined". Additionally, the beneficiary must be informed that only one practitioner can furnish and be paid for these services during a calendar month and of their right to stop CCM services at any time.

c)  24/7 Access

2015 CMS guidelines established 24/7 access to CCM services addressing a beneficiary's urgent chronic care needs. Guidance per the 2017 MPFS Final Rule states "after-hours services typically would and should address any urgent needs." As such, the scope of service criteria has been altered such that the beneficiary will have access to physicians or other qualified health care professionals or clinical staff 24 hours a day, 7 days a week, to address "urgent" needs rather than "urgent chronic care needs".

d)  Care Plan Accessibility

A pillar of CCM scope of services as outlined in 2015, was the "creation, revision and/or monitoring (as per code descriptors) of an electronic patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports."

Accordingly, prior reporting criteria mandated not only electronic capture of care plan information but also the electronic accessibility, on a 24/7 basis of the care plan to all practitioners within the practice whose time counts toward the time requirement to bill the CCM code. Further required, was the sharing and accessibility of the care plan information electronically (other than by fax). Extensive feedback from the public was instrumental in amending this provision and effective January 1, 2017, the care plan does not need to be available remotely to individuals providing CCM services after-hours which is a profound change, promoting greater flexibility for beneficiaries to access these services.

e)  Continuity of Care and Managing Care Transitions

Relative to continuity of care, the CCM scope of service as previously defined called for "a designated practitioner or member of the care team with whom the beneficiary is able to get successive routine appointments." Acknowledging that the billing practitioner is a member of the CCM care team, the word "practitioner" has been removed such that continuity of care is accomplished when the beneficiary is able to schedule successive routine appointments with a "designated member of the care team."

Also significant, the requirement for clinical summaries in managing care transitions has been modified to embody a continuity of care document enabling care transitions to be executed with the creation and exchange of continuity of care document(s) in place of the requirement that clinical summaries be created and formatted according to certified EHR technology.

As such, CMS will no longer require "the use of any specific electronic technology in managing a beneficiary's care transitions as a condition of payment for CCM services." This includes referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities. Per the final rule, continuity of care document(s) are drawn from CPT prefatory language for Transitional Care Management ("TCM") services, stating the continuity of care document may include "obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care document)."

Further, CMS no longer specifies how care management or continuity of care documents be transported or exchanged as long as it is done "timely" and consistent with management of care transitions scope of service element.

f)   RHC and FQHC Impact

Rural Health Clinics ("RHC") and Federally Qualified Health Centers ("FQHC") have been able to report CCM services since January 1, 2016. Payments for services rendered by RHCs and FQHCs are not adjusted for length of complexity of visit; therefore, the newly compensable codes 99487, 99489 and G0506 will not be separately billable by an RHC or FQHC. Changes surrounding scope of service, billing requirements and conditions of payment that were finalized to the 2017 MPFS will, however, apply in these settings.

SunStone will devote further HotStone articles to documentation, coding and billing nuances related to the new CPT and HCPCS codes. SunStone offers a full Service Line specifically geared to assisting hospital based and independent multi-specialty physician groups manage the ever changing professional regulatory environment.

If you have any questions about the 2017 Physician Coding and Policy Updates, please contact Vonda Moon, Principal at or Joli Fitzgibbons, Manager at