Background

Beginning January 1, 2020, physician practices can bill and receive reimbursement for delivering care management services to Medicare beneficiaries with a single chronic condition using newly established HCPCS G-codes for Principal Care Management (PCM).

As explained in its recent Medicare physician payment final rule, the Centers for Medicare and Medicaid Services (CMS) “heard from a number of stakeholders, especially those in specialties that use the office/outpatient E/M code set to report the majority of their services, that there can be significant resources involved in care management for a single high-risk disease or complex chronic condition that is not well accounted for in existing coding.”

To address this gap, the agency established two new billing codes that CMS anticipates “will be billed when a single condition is of such complexity that it cannot be managed as effectively in the primary care setting, and instead requires management by another, more specialized, practitioner.” While there are no restrictions on who can deliver PCM services, CMS expects that specialists who are focused on managing patients with a single complex chronic condition requiring substantial care management will bill PCM services the most.

CMS also explains that “a qualifying condition will typically be expected to last between 3 months and 1 year, or until the death of the patient, may have led to a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”

New Codes for PCM Services

The CMS-established codes for PCM services are as follows:

• G2064: Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other 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.
• G2065: Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. General Supervision is allowed.

CMS describes a typical patient as one that “may present to their primary care practitioner with an exacerbation of an existing chronic condition.” The agency goes on to explain that, “[a]lthough the primary care practitioner may be able to provide care management services for this one complex chronic condition, it is also possible that the primary care practitioner and/or the patient could instead decide that another clinician should provide relevant care management services. In this case, the primary care practitioner will still oversee the overall care for the patient while the practitioner billing for PCM services will provide care management services for the specific complex chronic condition. The treating clinician may need to provide a disease-specific care plan or may need to make frequent adjustments to the patient's medication regimen. The expected outcome of PCM is for the patient's condition to be stabilized by the treating clinician so that overall care management for the patient's condition can be returned to the patient's primary care practitioner.”

CMS also anticipates that “many patients will have more than one complex chronic condition” and that a patient “could receive PCM services from more than one clinician if the patient experiences an exacerbation of more than one complex chronic condition simultaneously.”

Additional Criteria for Billing PCM Services

A table outlining criteria that must be met in order to bill PCM services, which are similar to that of Chronic Care Management (CCM) services, is below. In addition, CMS states that PCM services should not be furnished with other care management services by the same practitioner for the same beneficiary, nor should PCM services be furnished at the same time as interprofessional consultations for the same condition by the same practitioner for the same patient. Further, PCM codes should not be billed during the global surgical period, in conjunction with behavioral health integration services, and monthly capitated ESRD payments.

CMS set the Medicare national average payment for PCM services at approximately $84 for G2064 and $56 for G2065.

Future Considerations

In comments on the proposed policy for PCM services, stakeholders suggested that CMS establish a separate add-on code for additional time spent furnishing PCM services beyond the initial 30 minutes. for possible future rulemaking. Other commenters encouraged the agency to work with the American Medical Association (AMA) CPT Editorial Panel to develop coding for this service. CMS states that it will be monitoring billing of these services, and based on stakeholder feedback, will make refinements in future rulemaking, as warranted. The agency also said it would review and consider recommendations from the AMA CPT Editorial Panel and Relative Value System Update Committee (RUC) for these or similar services.