Preventative Medicine – 2017 Physician Coding Reimbursement & Policy Updates

On November 2, 2016, the Centers for Medicare and Medicaid Services (“CMS”) issued revisions to payment policies and payment rates under the Medicare Physician Fee Schedule (“MPFS”) for services provided by physicians, non-physician practitioners (“NPPs”) and other healthcare professionals paid under the MPFS furnished on or after January 1, 2017.  The final rule contains significant updates specifically targeted at reimbursing practitioners for preventative and/or alternative medicine services beginning on January 1, 2017.

I. Chronic Care Management - Coding and Policy Modifications

Among the 2017 updates are newly compensable codes for more time-intensive care management services provided to patients with multiple chronic conditions by primary care physicians and other practitioners. Recognizing care management as a critical component of primary care, in 2015 Medicare incorporated CPT 99490 into the MPFS allowing payment of care management activities that occurred beyond what was included in the face to face payment for Evaluation and Management (“E&M”) services for patients with two or more chronic conditions.

CMS reports that the utilization of Chronic Care Management (“CCM”) Services has been low since adopting payment for CCM visa vie CPT 99490 and in its 2017 final rule, CMS cites that only 513,000 Medicare beneficiaries have had a claim submitted despite millions of potentially eligible patients. Further acknowledged in the final rule “many practitioners have stated that the service elements and billing requirements are burdensome” with practitioners reporting spending 45 minutes to one hour per month on CCM services.

The valuation of CPT 99490 set up in 2015 allows for a minimum of 20 minutes.  The newly established CPT 99487, Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month will enable providers to be compensated for those more time intensive cases.  Additionally, CPT code 99489may also be reportedfor each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

Also adopted in the 2017 MPFS is a unique add-on service code for initiation of CCM services, HCPCS G0506, Comprehensive assessment of and care planning for patients requiring CCM services.

Several other changes intended to eliminate barriers for reporting CCM services are incorporated into the final rule such as revisions to technology, written consent, 24/7 care access and initiating visit requirements.  The more relaxed conditions for payment are targeted at providing greater access for beneficiaries, as well as reimbursing the practitioners for the complexity involved in managing the patient.

II. Payment for Prolonged Services

Previously considered bundled, CY 2017 MPFS allows for payment of CPT 99358, Prolonged evaluation and management service before and/or after direct patient care, first hour; and CPT code 99359 may be reported for each additional 30 minutes. Prolonged services codes may be reported for time spent on a different day than the companion E&M service. In the 2017 final rule CMS asserts “we intend these codes to be used to report extended non face-to-face time that is spent by the billing physician or other practitioner (not clinical staff) that is not within the scope of practice of clinical staff, and that is not adequately identified or valued under existing codes or the 2017 finalized new codes”.

III. Medicare Diabetes Prevention Program Expanded Model

CMS designates the Medicare Diabetes Prevention Program (MDPP) as a preventive service in the 2017 MPFS Final Rule citing prevention of type 2 diabetes as the goal of the MDPP expanded model which will be available to eligible beneficiaries beginning January 1, 2018. The MDPP core benefit consists of 12 months of sessions using a CDC-approved DPP curriculum of at least 16 core sessions furnished over a range of 16-26 weeks, and a 6-month core maintenance session over weeks 27-52 (second 6 months) with a goal of 5% minimum weight loss. Although CMS will address payment for MDPP services in future rulemaking, suppliers will be afforded the opportunity to adopt a CDC-approved curriculum and enroll in CY 2017.

IV. Mental and Behavioral Health Changes Incorporate Comprehensive Care Model

Promoting a team-based approach to mental and behavioral health conditions under the Psychiatric Comprehensive Care Model (“CoCM”), the 2017 MPFS reimburses for three new collaborative care management HCPCS codes G0502, G0503 and G0504 which involve “psychiatric collaborative care management” between a supervising physician, a behavioral healthcare manager and a consulting psychiatrist. G0502 is the initial psychiatric collaborative care management code requiring 70 minutes for the first month of behavioral healthcare management activities; G0503 requires 60 minutes in subsequent months; and G0504 is a 30-minute add-on code. Additionally, G0507 is a general behavioral health intervention code which covers 20 minutes of care management services for behavioral health conditions per month.

V. Payment for Cognitive Impairment Assessment and Planning

Under the CY 2017 Final Rule, HCPCS code G0505 recognizes the work of a physician or other appropriate non-physician practitioner in assessing and creating a care plan for beneficiaries with cognitive impairment, such as from Alzheimer’s disease or dementia. G0505, a temporary code, is defined as Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiving, in office or other outpatient setting or home or domiciliary or rest home.

VI. Reporting for Patients with Mobility-Related Impairments

CMS proposed add-on code G0501, effective CY 2017, described as additional services furnished to beneficiaries with mobility-related impairments. Although not payable under the MPFS for CY 2017, practitioners will be able to begin reporting this add-on code which can be billed with new and established E&M codes as well as transitional care management codes when the additional resources described by the code are medically necessary and used in the provision of care. Before payment is finalized for code G0501, in the CY 2017 final rule, CMS cites that they will “continue to explore improvements in payment accuracy for care of people with disabilities”.

VII. Valuation of Moderate Sedation Services

CMS revalued the Relative Value Units (“RVUs”) of over four hundred (400) diagnostic and therapeutic procedures that previously included moderate sedation as an inherent part of the service, to address unbundling of moderate sedation from those diagnostic and therapeutic procedures.  Accordingly, six (6) new moderate sedation codes will be recognized and compensable beginning January 1, 2017.

It is vital when performing moderate sedation with a procedure that providers establish mechanisms to begin capturing and reporting CPT codes 99151-99157. In addition to the six (6) new moderate sedation codes approved for 2017, HCPCS code G0500 has been incorporated into the MPFS as “moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older”.

VIII. Telehealth Services

A new Place of Service (“POS”) code 02; Telehealth, is to be reported for telehealth services furnished on or after January 1, 2017 for services provided or received through telecommunication technology.

Critical Care consultations compensable through two new HCPCS codes, G0508 and G0509, End Stage Renal Disease (“ESRD”) related services CPT codes 90967 through 90970, and Advance Care planning CPT codes 99497 and 99498 are among additions to the expanded list of telehealth services reimbursed under CY 2017 MPFS.

IX. Reporting Data on Post-Operative Visits to Impact Nine States

Effective July 1, 2017, practices in the states of Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon and Rhode Island will be required to report visits normally included during either a 10-day or 90-day global period.

Claims-based reporting using CPT 99024 will begin July 1, 2017 only for practices with 10 or more practitioners in these nine (9) states. In the final rule, CMS encourages practitioners to begin reporting post-operative visits for procedures furnished on or after January 1, 2017, but the mandatory requirement to report will be effective for services related to global procedures furnished on or after July 1, 2017. According to the final rule, CMS will issue a list of codes on its website for which it will require global period reporting.

X. Physician Fee Schedule - Increase in Conversion Factor

The 2017 Physician Fee Schedule conversion factor is set to $35.89, representing a $.09 increase from 2016. In the final rule, CMS finalized miss-valued code changes achieving a net reduction in expenditures of .32 which was less than the .5 target for 2017 and after applying this and other adjustments, arrived at the $35.89.

XI. Quality Payment Program

On October 14, 2016 the Department of Health and Human Services issued its final rule implementing the Quality Payment Program (“QPP”) under the Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”). Providers will select from two (2) QPP tracks by participating in either Advanced Alternative Payment Models (“APMs”) or the Merit-Based Incentive Payment System (“MIPS”). Predicated on 2017 participation and data reported, 2019 Medicare payments will either be adjusted up, down, or not at all. The first performance period under the QPP commences on January 1, 2017.

SunStone will devote further HotStone articles to documentation, coding and billing nuances related to the new CPT and HCPCS codes and 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, Georgia Rackley, Senior Clinical Specialist at, or Cathy Archuleta, Senior Consultant at