Health System Reform Insight - Oct. 20, 2011
Given the new direction for the nation’s health system, the AMA has developed Health System Reform Insight to help you understand what this new direction means to you and your patients.
On July 19 the Centers for Medicare & Medicaid Services (CMS) announced it would address concerns regarding payment for care provided to patients with chronic diseases. CMS was especially interested in addressing this issue for primary care physicians, who are most often responsible for the care and management of patients with these complex health issues.
CMS envisioned that reviewing the valuation for existing evaluation and management (E/M) visits would accomplish this goal. However, numerous national medical specialty societies were concerned that such a limited review would not address the broader objective of rewarding physicians for improved care coordination.
Consequently, the AMA's CPT® Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC) created the Chronic Care Coordination Workgroup (C3W) to provide strategic direction to address the adequacy of coding as well as the valuation of care coordination services and management of chronic diseases. While ensuring that coding and payment systems accommodate care coordination will be a long-term effort, a number of mechanisms are already in place that would allow CMS to begin rewarding such care immediately.
On Oct. 3, the RUC called on CMS to begin paying for the following Medicare services beginning Jan. 1:
Anticoagulant management (CPT codes 99363 and 99364):
By paying for CPT codes that describe stroke-prevention management, CMS would signal that it is serious about providing incentives for care coordination. These services are cost effective, eliminating unnecessary face-to-face physician services that are required when Medicare does not pay for care management.
Multiple specialty societies support payment for these CPT codes, and such payment is completely aligned with CMS's stated goals for transforming the payment system into a vehicle for quality improvement and cost savings. There is ample evidence that better anticoagulation management can reduce thromboembolic and bleeding events that are devastating to Medicare patients and increase health care costs.
Education and training for patient self-management (CPT codes 98960–98962):
In 2006 the CPT Editorial Panel implemented these three codes to describe patient education and training. While CMS accepted the RUC's recommendation to recognize direct practice expense inputs, it implemented the codes as bundled within E/M services. However, these services are clearly separate and distinct from E/M services, requiring non-physician clinical staff to provide 30 minutes of education.
Medical team conference (CPT codes 99366–99368):
When a physician is involved in a team conference with the patient and other health care professionals, the physician may report an E/M service. However, if the patient is not present (CPT 99367), Medicare does not allow the physician to report his or her services separately. Likewise, non-physicians—such as dieticians, physical therapists and occupational therapists—are not allowed to separately report the time that they spend in team conferences, whether the patient is present (CPT 99366) or not (CPT 99368).
Similar to the education and training codes described above, it is important to recognize these time-based team codes to capture real costs to a physician's practice.
Telephone services (CPT codes 99441–99443 and 98966–98969):
In the past, technical issues related to audit standards and appropriateness precluded CMS from considering separate payment for telephone services. But the CPT Editorial Panel's revisions to the CPT guidebook in 2008 and the RUC's recommendations provide a path to appropriately pay for these services. Documentation for these services is required, and the instructions for reporting them are clear. Medicare payment for telephone calls would reward physicians for this care coordination activity.
Immediately implementing payment for these non-face-to-face care coordination codes would provide resources for physicians to care for complex patients even as medical home and other models of payment for these patients are developed. CMS's response to these recommendations from the RUC and comments from national medical specialty societies is anticipated in the 2012 Medicare Physician Payment Schedule final rule, which is expected to be released Nov. 1.
Nov. 1
Physicians who wish to file for an exemption from the 2012 ePrescribing penalty must apply by this date. Submit an application. If you have difficulty accessing the online application, email QualityNet, which runs the portal.
Nov. 23
The Joint Select Committee on Deficit Reduction is due to approve a proposal to reduce federal spending by at least $1.2 trillion. Tell Congress that repeal of Medicare's flawed sustainable growth rate formula must be part of the committee's proposal.
