CMS proposes some revised requirements for chronic care

It is important for internists to understand and plan for how they could meet the proposed service requirements and take advantage of payment for non-face-to-face chronic care management.


Non-face-to-face care as part of complex chronic care management is an integral service provided by internal medicine specialists, and ACP has been diligently working to develop codes that payers would recognize for reimbursement. The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule for how Medicare may begin to pay for these services; therefore, it is important for internists to understand and plan for how they could meet the proposed service requirements and take advantage of payment for non-face-to-face chronic care management.

In July 2013, CMS proposed adding 2 codes to represent chronic care management, GXXX1 and GXXX2, and providing separate payment for them. These codes were placeholders that would potentially be specified in a final rule. In December 2013, CMS reduced the 2 codes to create 1 new alphanumeric G code for chronic care management, GXXX1; however, CMS did not finalize the value of this G code and noted that it would be establishing this value, as well as additional criteria that must be met by physicians in order to bill for the new code in future rulemaking.

Following the 2013 final rule, ACP worked with other medical societies to develop CPT code 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) in an effort to address the general policy parameters that CMS had laid out for the chronic care management code during the 2013 rulemaking process.

The current proposed rule now serves to outline CMS’ plans for this new G code. Chronic care management services as described in this code must be furnished to patients for 20 minutes or more during a 30 day period. The work RVU for the CCM code GXXX1 is proposed for 0.61, down from the 1 work RVU recommended by the Relative Value Update Committee for proposed CPT code 99487; however, the CPT code proposal was not accepted by CMS in the proposed rule. The estimated payment for code GXXX1 is $43.67. Those billing the proposed code must meet the following service requirements:

  • be able to demonstrate the use of written protocols;
  • provide 24/7 access to address a patient's acute chronic care needs. The patient would be given a means to contact the practice's clinicians in a timely manner. Members of the chronic care team would have access to the patient's electronic medical record, even when the office itself is closed; and
  • provide continuity of care with a designated clinician or member of the care team with whom the patient would be able to obtain successive routine appointments.

CMS has recognized the need to continue to develop the scope of service requirements based on public comments to the last year's proposed rule, including comments from ACP. These requirements, which practices must meet in order to bill for this code, are an area about which ACP has expressed concern, provided feedback, and sought clarification. In this year's proposed rule, CMS has made an effort to simplify certain practice requirements with regard to chronic care management.

Photo by Thinkstock
Photo by Thinkstock

First, CMS has proposed removal of the requirement that clinical staff participating in the chronic care management of a patient be direct hires of the physician or the practice. Second, CMS is proposing to allow clinical staff time under general supervision to be counted toward chronic care management at any time of day (even outside of normal business hours) as long it meets the general supervision requirements (as opposed to the 2013 proposal, which was more restrictive).

CMS is also proposing that chronic care management services be performed with the use of EHRs or other health information technology information exchange platform. At the very least the EHR must meet the standard of data capture of demographics, problem lists, medications, and other elements required to create an electronic summary record. The electronic data must be accessible to all practitioners providing care during and after normal business hours.

Another proposal in the rule is related to the Multi-Payer Advanced Primary Care Demonstration and the Comprehensive Primary Care Initiative. CMS is proposing that clinicians participating in such models would not be able to bill for chronic care management because this would cause duplicative payments (because of the overlap in service payments). Although these clinicians are not able to use the chronic care management code for patients included in the demonstration models, they may use the chronic care management code for other patients that meet the criteria, even though this may be a limited number.

In addition, the proposed chronic care management code would not be billable in conjunction with the transitional care management codes (CPT 99495 and 99496), the home health care supervision code (HCPCS G0181), the hospice care supervision code (HCPCS G0182), or the codes for end-stage renal disease services (CPT 90951-90970).

Elements of the scope of service that are to be included in a 30-day period for chronic care management were outlined by CMS in December 2013:

  • a systematic assessment of the patient's medical, functional, and psychosocial needs;
  • system-based approaches to ensure timely receipt of all recommended preventive care services;
  • medication reconciliation with review of adherence and potential interactions;
  • oversight of patient self-management of medications;
  • a comprehensive, patient-centered care plan written in consultation with the patient and with other key practitioners who are treating the patient, based on physical, mental, cognitive, psychosocial, functional, and environmental assessment and reassessment, and an inventory of resources and supports, assuring that the care provided is harmonized with the patient's wishes and values;
  • management of care transitions within health care, including referrals to other clinicians, visits that follow an emergency department visit, and visits following discharge from hospitals and skilled nursing facilities;
  • coordination with home- and community-based clinical services; and
  • enhanced opportunities for the patient to communicate with the clinician, to include not only the telephone but also secure messaging, Internet communication, or other same-time consultation methods.

Also, clinicians would bill just 1 unit of chronic care management in a 30-day period. The billing would not occur prior to the 30th day. (ACP will request that CMS clarify whether this is to be counted in business days or calendar days). If a face-to-face visit were to occur within the 30-day chronic care management reporting period, it would be separately billable.

Patients that would like to receive the benefits of chronic care management would need to be notified of and consent to the scope of chronic care management services before a physician can bill for them. As evidence that such consent occurred, the physician would note it in the patient's medical record and the patient would be given a copy (printed or electronic) of the plan. Consent would be reaffirmed at least once every 12 months. The patient would be able to revoke consent at any time.

Overall, ACP views this proposal as a positive development for internal medicine; however, staff will provide comments to CMS to improve upon the value of and requirements for this code.