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New Medicare Codes for Care Coordination: Good for Providers?


CMS has five new CPT codes regarding care coordination for family physicians and there are clear pros and cons.

CMS has created five new CPT codes for family physicians. The first two will reimburse for post-discharge transitional care coordination (99495 and 99496) and three for complex care coordination, evaluation, and management (99487-99489).

The first two, which do not require face-to-face visits, increase payments to family physicians by about 7 percent and to other primary-care providers between 3 percent and 5 percent. The latter three require direct contact with the patient, including a face-to-face visit related to the patient’s chronic care. These codes cover only office-based services.

While this is welcome news for primary-care physicians at face value, these new codes and two more that are proposed are leading to a place that many family practices may not want to go.

Here’s how CMS sets things up: The agency says it has recently “recognized primary care and care coordination as critical components in achieving better care…” and wants to “encourage long-term investment in primary care and care-management services” through “accurate payment.”

The agency also contends that it will continue “ hear concerns from the physician community...”

Here are three:

1. Since only primary care is eligible for reimbursement, the entire responsibility for coordinating care falls on primary-care practices, many of which will have to invest further in people, procedures, and systems to manage it.

2. Focusing on processes such as care coordination and transition only better manages the process.

3. Rewarding process improvement is a step forward in efficiency, but a step away from a solution - such as also investing in physicians to engage, educate and equip patients to do their part to succeed in the treatment and prevention of chronic conditions in ways that they can understand.

CMS sort of addresses the latter of the concerns by offering up something under the auspices of the ACA: an HCPCS G-code that specifically pays for “post-discharge transitional care management services.” 

In the agency’s words, the proposed code will pay for “all non-face-to-face services related to the transitional care management … within 30 calendar days following the date of discharge from an inpatient acute-care hospital, psychiatric hospital, long-term care hospital, skilled nursing facility, and inpatient rehabilitation facility; hospital outpatient for observation services or partial hospitalization services; and a partial hospitalization program at a community mental health center to community-based care.”

Of the 11 primary tasks on the punch list for this new code, four recognize that there is an actual patient involved, and represent the bulk of the work required to qualify, and I paraphrase again:

1. Establishing a personalized plan of care with the patient;

2. Being sure the patient or caregiver understands their medications;

3. Educating the patient or caregiver about the home care plan, potential complications, and what to do if they happen; and

4. Helping the patient or caregiver to determine and establish any needed home services and community-based resources.

The American Academy of Family Physicians estimates that payment for two new codes (99495 and 99496) would be about $94.62. CMS is estimating the codes would apply to about 10 million discharges in 2013.

Since this proposal is subject to budget neutrality policies, it would move about $95 million annually from other services to primary care.

That would be taking money from those that primary care is coordinating with. That helps to seal the deal that the plan may well be for primary care to own care coordination and transition exclusively.

On the upside, local or regional care-coordination services and care-planning platforms such as DocInsight’s “MyHomeCare Plan” can make the load more manageable.

On the downside, since primary care picks up the tab, what looks like a windfall may prove to be much less so, and even a headwind for some.

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