AMA Asks Medicare to Pay for More Care-Coordination Codes

September 09, 2015

Imagine getting paid for sitting down with a nutritionist and a nurse practitioner to discuss how to manage a Medicare patient with diabetes, even though the patient is not present.

Or getting paid for analyzing a patient's blood pressure and glucose readings transmitted from his or her home to the office.

Or getting paid for simply talking with the patient on the telephone.

Those possibilities are on the table as the Centers for Medicare & Medicaid Services (CMS) and organized medicine discuss the future of Medicare reimbursement. Earlier this year, in its proposed Medicare fee schedule for 2016, CMS invited the medical profession to suggest additional evaluation and management (E/M) services that it could cover. In response, the American Medical Association (AMA) has suggested six E/M services that have their own billing codes, but no Medicare reimbursement attached to them as of yet.

Table. E/M Services With Billing Codes but No Medicare Reimbursement

E/M Service Current Procedural Terminology Code or Range of Codes
Anticoagulant management 99363 - 99364
Medical team conference 99366 - 99368
Telephone services 99441 - 99443
Education and training for patient self-management 98960 - 98962
Analysis of computer transmitted data 99091
Complex chronic care management services 99487 - 99489

Covering these services, the AMA wrote CMS, "will represent a monumental step in the burgeoning movement to reform healthcare by moving away from the current culture of paying for disjointed, duplicative, and inefficient care."

The American College of Physicians (ACP) proposed paying for additional E/M services that do not involve face-to-face contact with the patient. Among these are online medical evaluation and care plan oversight for home and hospice care.

"Caring for patients with chronic illnesses requires care outside the office visit, much of which is not captured in statistical data or separately reimbursed under current Medicare guidelines," the ACP stated in a letter to CMS regarding the proposed 2016 fee schedule.

Another major society representing primary care physicians, however, threw cold water on the notion of covering more E/M codes, given systemic flaws in E/M reimbursement that lowball what primary care physicians do.

"The idea of creating add-on codes for the current E/M codes is like building an addition onto a house with a very poor foundation," the American Academy of Family Physicians (AAFP) told CMS. The AAFP recommended that before CMS decides to cover more E/M codes, it should overhaul its E/M coding system to ensure payment accuracy.

Major Medical Societies Pleased With Advance Care Planning Fee

Medicare coverage of more E/M codes represents just one small facet of the proposed 2016 Medicare fee schedule, which runs to more than 800 pages.

Issued in July, the schedule reopened the controversial subject of reimbursing physicians for advance care planning; that is, discussing advance directives, hospice care, and other end-of-life issues with patients. This idea, originally contained in an early version of the Affordable Care Act, prompted many critics of the law to argue that CMS wanted to hasten the death of the elderly through fictitious "death panels."

Giving physicians a separate fee for advance care planning, however, has long enjoyed support from most of organized medicine, which was reflected in the letters that CMS received in response to its proposed 2016 fee schedule. The AMA said it was "very pleased" with the prospect of the new fee in 2016. Likewise, the ACP said it "applauds" the decision.

One voice of dissent was the politically conservative Association of American Physicians and Surgeons. The small but vocal society warned CMS that payment for advance care planning would "create financial incentives to persuade patients to consent to the denial of care."

A good portion of the proposed fee schedule focused on how CMS should implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which abolished Medicare's sustainable growth rate formula for setting physician reimbursement. MACRA replaces the formula with a scheme combining fee-for-service and pay-for-performance, considered the wave of the future.

One MACRA pillar is the Merit-Based Incentive Payment System (MIPS), which will consolidate the electronic health record incentive program, the Physician Quality Reporting System, and the value-based modifier program. Physicians will see their fee-for-service payments adjusted upward or downward, depending on how they score on various measures of clinical quality, cost control, meaningful use of electronic health records, and clinical practice improvement.

CMS said in its proposed 2016 fee schedule that it would exclude physicians from MIPS if their Medicare patient volume was low. The agency solicited feedback on perhaps making the cutoff less than 10% of a physician's total volume. In response, the AAFP said it preferred making the threshold a minimum absolute number of Medicare patients, once CMS researched what would be an appropriate number. The ACP recommended making physicians potentially eligible for MIPS if they have at least one Medicare patient, provided that performance measures make sense for whatever head count there is. The AMA essentially punted on the issue, saying that it would discuss it in greater detail with more state and national medical societies before weighing in.

CMS had another MIPS question to ask: What kind of activities would qualify as clinical practice improvement? The agency suggested general categories, such as expanded practice access and care coordination. It asked stakeholders for specific examples. Extended clinic hours ought to count, said the AAFP, as well as group visits and motivational interviewing. The ACP added to the list participation in the government's Million Hearts Initiative or a local hospital's quality improvement project. The AMA again said that it would get back to CMS on this matter.

The deadline for submitting comments on the proposed 2016 fee schedule was September 8. CMS typically releases its final fee schedule for the upcoming year later in the fall.