Posts Tagged ‘primary care’

Medicare’s Care Coordination Codes – New In 2013

In Uncategorized on August 23, 2013 at 5:21 pm

CMS created five new CPT codes for family/primary care physicians use in 2013. The first two will reimburse for post-discharge transitional care coordination (99495 and 99496), do not require face-to-face visits, and are anticipated to increase payments to family physicians by about 7 percent and to other primary-care providers between 3 percent and 5 percent.  The other three relate to complex care coordination, evaluation, and management (99487-99489), require direct contact with the patient, including a face-to-face visit related to the patient’s chronic care, and 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 “…to hear concerns from the physician community…” Such voiced concerns include the following:

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

  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.

So what may have appeared to be a windfall may prove to be much less so in practice.


Primary Care Providers Should Have Seen Fee Increases in 2013!

In Uncategorized on August 22, 2013 at 9:11 pm

In 2013, family physicians, general internists, and pediatricians experienced some Medicare and Medicaid pay increases due to two final rules that had been released by CMS.

Here’s a brief look at each of the rules and the reimbursement-related changes they included:

Higher Medicaid Pay: As a result of one of the rules, released in early November, Medicaid payments to family medicine, general internal medicine, and pediatric medicine physicians will match Medicare levels in 2013 and 2014. The higher payments also apply to primary-care services provided by nurse practitioners and physician assistants who are under the supervision of a qualifying physician.

The pay hike is meant to encourage doctors to see additional Medicaid patients, for as a result of the Medicaid expansion portion of the Affordable Care Act, an additional 17 million more patients are expected to gain insurance in 2014.

While the pay increase is a “step in the right direction,” AAFP President and family physician Jeffrey Cain said in a statement that the temporary nature of it is troubling.  “Unless Congress acts to permanently extend and fund this provision, a sudden return to disparate and inadequate payment for primary-care services needed by Medicaid patients after only two years will again threaten to restrict their access to such needed services,” he said.  “Only by extending Medicaid parity with Medicare can we ensure that these Americans continue to have uninterrupted medical care in the future.”

New Payments: The 2013 Medicare Physician Fee Schedule final rule, also released in early November, establishes that primary-care physicians will receive separate payments for coordinating a patient’s care during the 30 days after a patient is discharged from the hospital. In total, these additional care-coordination payments are expected to increase family physician pay by 7 percent, and increase other primary-care physicians’ pay by 3 percent to 5 percent, according to CMS.   See the next section of this memo for a more detailed look at the coordination of care codes.

One of the critical issues raised in the Proposed Rule was what constitutes a primary care provider?  The PPACA identified the specialties of Family Medicine, General Internal Medicine and Pediatrics, as being “primary care.”  However, CMS opened the door to sub-specialists by proposing that they would consider sub-specialists within those general specialties as being “primary care” as well.  CMS specifically proposed that services provided by sub-specialists within the primary care categories designated in the statute would also qualify for higher payment. These would be sub-specialists recognized in accordance with the American Board of Medical Specialties (ABMS) designations.

The ABMS recognizes the following sub-specialties within the three statutorily referenced specialties:

 Family Medicine

Adolescent Medicine Geriatric Medicine
Hospice and Palliative Medicine Sleep Medicine
Sports Medicine  


Adolescent Medicine Pediatric Transplant Hepatology
Developmental-Behavioral Pediatrics Pediatric Medical Toxicology
Pediatric Emergency Medicine Pediatric Neonatal-Perinatal Medicine
Pediatric Pulmonology Pediatric Rheumatology
Pediatric Infectious Diseases Pediatric Nephrology
Pediatric Gastroenterology Pediatric Endocrinology
Pediatric Critical Care Medicine Pediatric Hematology-Oncology
Neurodevelopmental Disabilities Pediatric Cardiology
Sports Medicine Child Abuse – Pediatrics
Sleep Medicine Hospice and Palliative Medicine

Internal Medicine

Pulmonary Disease Rheumatology
Medical Oncology Nephrology
Infectious Disease Interventional Cardiology
Hematology Hospice and Palliative Medicine
Gastroenterology Geriatric Medicine
Critical Care Medicine Adolescent Medicine
Cardiovascular Disease Clinical Cardiac Electrophysiology
Sleep Medicine Sports Medicine
Endocrinology, Diabetes and Metabolism Advanced Heart Failure and Transplant
Transplant Hepatology  

During the public comment period, numerous medical specialty societies argued that CMS had inappropriately singled out ABMS as the only specialty Board CMS would recognize.  For example, the Proposed Rule excluded the American Osteopathic Association Board as well as the American Board of Physician Specialties (ABPS). 

After reviewing the comments, CMS has decided to expand the Boards (and associated sub-specialties) they will recognize.  CMS will now recognize both the AOA specialty designations under the heading of Family Practice, Internal Medicine and Pediatrics, as well as the ABPS specialty designations within the three recognized specialties. 

Finally, CMS will permit physicians who are not Board Certified, to “attest” that they provide primary care services.  For physicians who wish to “attest” they must demonstrate that at least 60% of the services they bill to Medicaid are for the codes designated as “primary care” codes.