CMS Proposes New Fee for Chronic Care Management

July 09, 2013

In a nod toward primary care, the Centers for Medicare & Medicaid Services (CMS) has proposed paying physicians a new fee — beginning in 2015 — for managing Medicare patients with 2 or more chronic conditions apart from face-to-face office visits.

Right now, the details are sketchy: CMS has yet to set the amount of the fee, and the agency is asking the medical profession to help it develop standards for earning the extra cash.

These loose ends notwithstanding, some physicians may find they will not qualify for the new management fee. "Potential standards," according to CMS, include the use of a certified electronic health record system, employment of at least a single nurse practitioner or physician assistant, and status as a medical home. Offering "complex chronic care management services" on a 24/7 basis is a "required capability."

Medicare reimbursement for evaluation and management (E/M) services already includes chores before and after a face-to-face encounter with the patient such as reviewing laboratory results and consulting with another clinician. However, physicians complain that billing codes for E/M services lowball the level of behind-the-scenes work needed to manage patients with knotty problems, CMS stated in its proposed fee schedule for 2014, which was issued yesterday.

By giving clinicians incentives to actively manage patients with multiple chronic illnesses, CMS sees an opportunity to improve the quality of care while cutting costs. In a study of Medicare fee-for-service beneficiaries with 15 major chronic illnesses such as hypertension, hyperlipidemia, and ischemic heart disease, the agency found that seniors with 4 or more conditions accounted for 37% of all beneficiaries, but 74% of total Medicare spending, in 2010.

The proposal for the new fee is part of the "broader multi-year strategy to appropriately recognize and value primary care and care management services," the agency stated. Just this year, CMS introduced a similar fee for "transitional care management services" for patients discharged from a hospital or skilled nursing facility.

Annual Wellness Visit Must Precede Management Services

The new fee would cover management of patients with "multiple complex chronic conditions" that are expected to last at least 12 months or until death and that put the patient "at significant risk of death, acute exacerbation/decompensation, or functional decline." One mandatory management service is developing a comprehensive care plan and keeping it up to date.

Physicians would bill Medicare for care-management services using 2 different G-codes. One G-code would cover services lasting at least 1 hour during an initial 90-day period. The second G-code would be for any subsequent 90-day period.

Under the CMS proposal, physicians would not be able to submit the G-codes unless the patient received Medicare's annual wellness visit within the previous 12 months.

Two Primary Care Societies Are Pleased

Leaders of 2 major primary care medical societies told Medscape Medical News that they are pleased with the government's proposal to reimburse physicians separately for chronic care management.

"It's a welcome step," said Shari Erickson, vice president of governmental and regulatory affairs at the American College of Physicians (ACP). "It's something we've been pushing for a long time."

Jeffrey Cain, MD, president of the American Academy of Family Physicians (AAFP), said the new fee is part of the evolution toward a payment system that recognizes that "patient care requires more than face-to-face time."

Both Erickson and Dr. Cain said their societies are still digesting the details of the CMS proposal. Both of them said their groups will lobby for final regulations that do not place unreasonable administrative demands on physicians who want to qualify for the new fee. "We recognize that it can be an uphill climb for some practices," said Erickson in reference to possibly requiring physicians to deploy an electronic health record (EHR) and employ a nurse practitioner or physician assistant.

Erickson said that the ACP prefers that official designation as a medical home does not become a prerequisite. That way, physicians who lack this designation still have a "nice pathway" toward payment models beyond traditional fee-for-service.

Dr. Cain said the rationale for the proposed management fee jibes with the medical home, designed to make patient care easily accessible, coordinated, and preventive in nature. Qualifying for medical-home status ought to help a physician qualify for the management fee. "You shouldn't have to check the box twice," said Dr. Cain about the hassles of duplicate documentation for different Medicare programs. However, medical-home status should not be the sole criterion for the fee.

The proposed CMS regulations on the new fee are scheduled for official publication in the Federal Register on July 19. CMS will accept comments on them until September 6 and then issue a final version of the regulations on or near November 1. The proposed regulations explain how the public can submit comments.

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