The 2020 Physician Fee Schedule and Care Coordination: What You Need to Know

Advancing the practice of care coordination is a vital part of the Centers for Medicare & Medicaid Services (CMS)’s 2020 Medicare Physician Fee Schedule Final Rule. Released late last year, the final rule’s whopping 2,475 pages include several new Medicare reimbursement rules aimed at boosting care coordination services, with new requirements affecting transitional care management, chronic care management, principal care management and remote patient monitoring. Most requirements took effect January 1.

Here are some insights into the Final Rule’s new requirements that affect care coordination:

Transitional Care Management (TCM). There’s growing evidence that TCM can improve outcomes, but its benefits aren’t being fully realized. A recent analysis of TCM claims data by CMS found that “beneficiaries who receive TCM services demonstrated reduced readmission rates, lower mortality and decreased healthcare costs.” However, in 2018, providers only submitted a fraction of claims as compared to that year’s eligible Medicare discharges.

One reason is likely due to the burden of billing for TCM services. To lighten the administrative load and increase utilization, CMS removed the prohibition on billing for chronic care management and care plan oversight provided during the 30-day TCM period. Now, a practitioner can bill for those services during the same TCM period.

Chronic Care Management (CCM). CCM is another underutilized reimbursement area despite evidence it can increase patient and practitioner satisfaction, save costs and enable solo practitioners to remain in independent practice, according to the CMS.

To increase utilization, CMS created an add-on code for non-complex CCM, allowing a practitioner to bill with one code for the first 20 minutes of clinical staff time spent on CCM activities in a given month and another code for the second and third 20-minute increments.

Principal Care Management (PCM). CMS will now reimburse for PCM services provided to beneficiaries with a single chronic condition, in contrast to the CCM’s services provided to those with two or more chronic conditions. The Final Rule also outlined some of the other key differences between CCM and PCM services, including: CCM’s scope involves total patient care management, whereas PCM manages disease-specific care; CCM is triggered by a general need for care coordination and communication, whereas PCM is triggered by an exacerbation of condition or hospitalization; and CCM is intended to be longer-term, as needed care, whereas PCM is shorter-term, until a patient’s condition is stabilized.

CMS also has established new requirements to prevent reimbursement for duplicative PCM services. Now, greater care coordination-related documentation is required between all practitioners providing care, and billing for interprofessional consultations or other care management services is prohibited. CMS will reimburse for PCM services provided directly by a physician or non-physician practitioner but not services provided by clinical staff under general supervision.

CMS declined to create an add-on reimbursement code for PCM time spent beyond 30 minutes per month. However, the agency has indicated it will monitor PCM utilization to see if future revisions need to be made.

Remote Patient Monitoring (RPM). CMS requires 20 minutes of clinical staff time per month reviewing and acting on RPM data and communicating with a patient or caregiver. But the supervision aspect has changed. CMS previously required the billing practitioner to provide direct, in-person supervision for clinical staff providing RPM services.  Under the new rule, CMS allows these services to be performed under general supervision.

Like the non-complex CCM add-on code, CMS has also created an RPM add-on code, allowing a practitioner to bill with one code for the first 20 minutes of clinical staff time spent on RPM activities in a given month and another code for the second and third 20-minute increments.

CMS also said future rulemaking will address commenters’ multiple complaints about the ambiguity of RPM code descriptions.

To learn more about the Final Rule’s reimbursement rules related to care management, sign up for HealthTechS3’s Jan. 23 webinar: “What’s New in the 2020 Physician Fee Schedule That May Impact Your Care Coordination Program?”

Previous HealthTechS3 webinars related to chronic care management (CCM) discuss how to formalize the CCM process in your clinic to ensure quality care and financial sustainability and how to take advantage of additional reimbursement opportunities related to RPM