Medicare’s new principle care management codes

Medicare’s 2020 rule has updates in regards to payment policies, coding, payment rates, other provisions for services furnished under Medicare Physician Fee Schedule (PFS). Synchronizing annualy with CMS apprises are challenging and many medical practices rely on outsourced medical billing companies for claims submission and timely reimbursements for services described as per revised codes. CY 2020, there’s one important update in evaluation and management of patients with multifaceted health care needs. CMS has newly introduced some codes in a new category of repayment named “Principal Care Management” (PCM) Services. These codes are expected to be billed by a physician managing a patient with single, complex, or high-risk condition.

New Principal Care Management” (PCM) code for one chronic condition

Chronic Care Management (CCM) CPT codes  CMS introduced in 2015 had a condition that a patient have a diagnosis of no less than two chronic conditions in order to bill Medicare for care management services. CMS have introduced a concept of Principal Care Management services to replace a gap in CCM codes, by, providing a care management services for patients with a single chronic condition. Two new PCM codes are HCPCS G2064 and HCPCS G2065:

• HCPCS G2064: Comprehensive care management services for a single high risk disease, e.g. Principal Care Management, at least 30 minutes of qualified health care professional time per calendar month with the following elements:

• • One complex chronic condition lasting at least 3 months, which is the focus of the care plan;
  • The condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization;
  • The condition requires development or revision of disease-specific care plan;
  • The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

• HCPCS G2065: Comprehensive care management for a single high-risk disease, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month with the following elements:

• • One complex chronic condition lasting at least 3 months, which is the focus of the care plan;
  • The condition is of sufficient severity to place a patient at risk of hospitalization or have been cause [sic] of a recent hospitalization;
  • The condition requires development or revision of a disease-specific care plan;
  • The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

Requisites for billing PCM services

• Both codes billed only a physician or qualified health care practitioner (QHCP). CMS expects PCM codes be used by specialties, including infectious disease, rheumatology, and pulmonology.
• Final Rule states PCM services will usually be generated by exacerbation of a qualifying condition that calls for disease-specific care (management by a specialized practitioner).
• PCM services are those provided to a patient with one serious chronic condition which is typically expected to last between 3 months and a year, or until the death of the patient.
• Code description states that condition may have led to a recent hospitalization and/or will place patient at significant risk for death, acute exacerbation/decompensation, or functional decline.
• Final Rule states that the expected outcome of provision of PCM services is for patient’s condition to be stabilized by treating specialist clinician so that overall care can be returned to patient’s primary care physician.
• New PCM codes are time-based and require development of a disease-specific care plan, informed verbal consent, and documentation of services provided by:

• • Physician, nurse practitioner, or physician assistant, for G2064
  • clinical staff, for G2065
• Physician may bill PCM simultaneously with Remote Physiologic Monitoring (RPM), but may not bill PCM with other care management codes (such as CCM) for same patient/month.
• While billing Chronic Care Management (CCM) codes requires a comprehensive care plan, billing PCM codes requires practitioner to develop a disease-specific care plan.
• PCM requires that communication/care coordination between all practitioners furnishing care to the beneficiary be documented by practitioner billing for PCM in patient’s medical record.
• HCPCS code G2065 allows for PCM services to be provided by clinical staff incident-to billing physician or QHCP.  Services should be provided under General Supervision, which means that billing practitioner must be available to answer clinical staff member’s questions and intervene when necessary, though they need not be co-located in same office as clinical staff member providing services.
• To initiate PCM services, billing practitioner has to conduct an initial face-to-face visit (this can be an annual wellness visit (AWV) or other separately billable visit). At the initiating visit, practitioner should educate patient on PCM, obtain patient’s verbal or written consent, and develop comprehensive care plan in electronic health record (EHR).

Accurate citations and coding are crucial for proper patient care as well as for getting reimbursed for services provided. Practitioners looking for help to bill CCM services using new codes can get support they need from an experienced physician billing company.