The Michigan Primary Care Transformation (MiPCT) Project Overview of 2017 CMS Proposed Physician Fee Schedule Diane Marriott (dbechel@umich.edu)

MiPCT Physician Fee Schedule Annual Comment Cycle CMS issues the draft schedule for the upcoming year (annually in late July) 60 day public comment period commences MiPCT assesses codes related to care management and population health and proposes draft response letter to SC SC members review, comment and provide signature approval for comment letter This year, comments are due Sept 6 by 5pm CMS issues revised and final schedule with comment theme responses (annually in Oct/Nov)

2017 Proposed PFS Changes – The 10,000 View Overall the 2017 proposed schedule incorporates two key improvement areas: New focus on care management and behavioral health issues Enhanced payment levels that for care of patients with multiple chronic conditions The following analysis is drawn from an excellent overview from Cardinal Health (August 2016 web release)

Five Key Improvement Areas Relevant to MiPCT Chronic care management (CCM) simplification (e.g., billing rules) Complex CCM payment Care plan development Payment Non-face-to-face prolonged evaluation and management (E/M) payment CCM supervision requirements for RHCs and FQHCs Behavioral health integration codes

1. CCM Simplification No required consent form Current rule:  A physician cannot bill for CCM unless and until the physician secures the beneficiary’s signature on a consent form, the contents of which are specified in the regulation. Proposed rule:  A physician may simply document in the medical record that certain information regarding CCM was furnished to the patient. Initiating visit Current Rule:  CCM must be initiated by the billing physician during a face-to-face E/M visit (Levels 2-5 E/M visit, an annual wellness visit, or initial “Welcome to Medicare” visit). Proposed Rule:  The initiating visit is required only for new patients and patients not seen within the last year.

1. CCM Simplification, cont. 24/7 access to care Current Rule:  The physician must provide the beneficiary with means to make timely contact with healthcare practitioners in the practice that has access to the beneficiary’s electronic care plan.  Proposed Rule:  The requirement regarding access to the beneficiary’s care plan is eliminated. Management of care transitions Current Rule:   The physician must create and exchange a clinical summary formatted according to certified EHR technology with other providers involved in the beneficiary’s care. Proposed Rule:  The continuity of care document does not have to be formatted in a specific manner.

1. CCM Simplification, cont. Sharing of care plan and clinical summaries Current Rule:   The physician must (a) make the electronic care plan available on a 24/7 basis to all practitioners within the practice whose time counts toward the time requirement, and (b) share care plan information electronically (by fax only in extenuating circumstances) as appropriate with other providers. Proposed Rule:  The electronic care plan must be made available in a timely manner within and outside the billing practice as appropriate, and care plan information must be shared electronically  (can include fax) within and outside the practice with those involved in the beneficiary’s care. Beneficiary receipt of care plan Current Rule:  The beneficiary must be provided with a written or electronic copy of the care plan. Proposed Rule:  The specification of the format in which the care plan is to be provided is eliminated.

1. CCM Simplification, cont. Documentation Current Rule:   A physician must document in a qualifying certified electronic health record communication to and from home-and-community- based providers regarding the patient’s psychosocial needs and functional deficits.  Proposed Rule:  Such communications must be documented in the patient’s medical record, but not necessarily a qualifying certified electronic health record.

2. Complex CCM Payment CMS proposes to make payment for complex CCM, CPT 99487. The billing rules for CCM (CPT 99490) and complex CCM are the same, except complex CCM requires 60 minutes of non-face-to-face care management services per month, as compared to 20 minutes for CCM.  CMS also proposes an add-on code for complex CCM, CPT 99489, for each 30-minute increment that goes beyond the initial 60 minutes.

2. Complex CCM Payment, cont. Projected national payment rates:

3. Care Plan Development CMS proposes to pay physicians for care plan development under a new code, GPPP7. The agency proposes the following description for this code: Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients receiving chronic care management services, including assessment during the provision of face- to-face services. This add-on code is to be listed separately in addition to the primary service and billed separately from monthly care management services. The projected payment rate for GPPP7 is $63.68 (non-facility) and $46.15 (facility).   

4. Non-Face-to-Face Prolonged E/M Services CCM and Complex CCM reimburse providers for time spent by clinical staff providing care management services, not time spent by physicians. Recognizing the additional resource costs involved in spending an extraordinary amount of time outside the office visit caring for an individual patient’s needs, CMS proposes to make payment under two codes: CPT 99358 – Prolonged E/M service before and/or after direct patient care, first hour CPT 99359 – Prolonged E/M service before and/or after direct patient care, each additional 30 minutes (listed separately in addition to CPT 99358)

4. Non-Face-to-Face Prolonged E/M Services, cont. In discussing these services, CMS warns the time counted for these codes must be beyond the usual service time for the primary or companion E/M code that is also billed; no time can be counted more than once towards the provision of CPT 99358 and 99359 and any other service reimbursable under the Medicare Physician Fee Schedule. The projected payment rate for 99358 is $113.41 (facility and non-facility); for 99359, it is $54.38 (facility and non- facility). 

5. CCM Supervision for RHCs and FQHCs For CCM services billed under the Medicare Physician Fee Schedule, the clinical staff providing the non-face-to-face care management services must be under the general supervision of a physician or non-physician practitioner. Thus, the clinical staff member does not have to be physically present in the same suite of offices when providing this service. Currently, however, clinical staff providing these services for RCH and FQHC patients still are subject to direct supervision, i.e., they must be physically present in the same suite of offices as a physician or non-physician practitioner who is available to provide assistance.  CMS now proposes to amend the regulations concerning RHCs and FQHCs, changing the direct supervision requirement to a general supervision requirement.  This will afford these rural and safety net providers greater flexibility in providing CCM services for their eligible patients.

6.Behavioral Health Integration “Behavioral Health Integration” (BHI) refers to discussions, information sharing, and planning between a primary care provider and a behavioral health specialist relating to the treatment and management of a patient with behavioral health conditions. CMS specifically references the psychiatric Collaborative Care Model (CoCM) as a model. Proposes separate payment for services using the CoCM beginning January 1, 2017, using three new G-codes: GPPP1, GPPP2 and GPPP3. These codes describe the requirements for initial and subsequent collaborative care management involving a behavioral health care manager working in consultation with a psychiatric consultant under the direction of the patient’s treating physician.

6.Behavioral Health Integ. (cont) Additionally, CMS proposes a new code for care management services for behavioral health conditions.  With the exception of the qualifying diagnosis, the billing requirements for GPPPX are the same as those for chronic care management. The proposed reimbursement for this code is approximately $3.00 more than the reimbursement for 99490 to cover the additional resources required to care for patients with behavioral health conditions.

6. Behavioral Health Integ. (cont.)

Draft Comment MiPCT Areas to CMS Reinforce concern that not waiving beneficiary financial liability will greatly reduce likelihood of use; Acknowledge CMS’ lack of statutory authority to waive payment, but suggest interagency discussion take place to pursue beneficiary financial waiver. Seek clarification that Transitional Care Management and Collaborative Behavioral Health Codes may be billed by CPC+ Practices Consideration of Greater Flexibility in Collaborative Behavioral Codes Interprofessional Consultation Encourage CMS to permit either face-to-face or non-face-to-face care management services or a combination, to meet the time requirements for CCM codes 99490, 99487 and 99489.

Questions/Suggestions? Contact Diane Marriott (dbechel@umich.edu)