Principal Care Management (PCM) Reimbursement under the 2020 Medicare Physician Fee Schedule
August Update: Read about the 2021 Proposed Medicare Physician Fee Schedule in our post summarizing proposed changes to Digital Health and Remote Patient Monitoring and our post about changes to Telehealth.
Update: Head to our resource page “Responding to COVID-19: Resources for Telehealth and Remote Patient Monitoring”
**This post is part of a series of blog posts related to the 2020 Medicare Physician Fee Schedule. Read more about remote patient monitoring and e-visits in our previous posts!**
How to Get Paid for Patient “e-Visits” under the 2020 Medicare Physician Fee Schedule; CMS Finalizes Changes to Remote Patient Monitoring in the 2020 Medicare Physician Fee Schedule;
The 2020 Medicare Physician Fee Schedule (the “Final Rule”), released on November 1, 2019, finalized two new codes in a new category of reimbursement titled “Principal Care Management” (PCM) Services. The new codes will be effective as of January 1, 2020, and provide reimbursement for managing a patient’s care for a single high-risk disease or complex chronic condition. They are described as follows:
HCPCS 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.
HCPCS G2065: Comprehensive care management for a single high-risk disease services [sic], 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 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 a patient at risk of hospitalization or have been cause [sic] of a recent hospitalization;
The condition requires development or revision of a 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.
What do the new PCM codes mean for the healthcare industry?
The concept of Principal Care Management services was created to fill a gap left by the Chronic Care Management (CCM) CPT codes that were established by the Center for Medicare & Medicaid Services (CMS) in 2015. The CCM codes require that a patient have a diagnosis of at least two chronic conditions in order for care management services to be reimbursable by Medicare. Under the new PCM codes, specialists may now be reimbursed for providing their patients with care management services that are more targeted within their own particular area of specialty. More generalized care management services may continue to be provided by a patient’s primary care physician as appropriate. Like the CCM codes, the new PCM codes may be billed concurrently with Remote Patient Monitoring codes (CPT Codes 99453, 99454, 99457, and 99091) and may be billed incident to a billing practitioner under general supervision of clinical staff providing the services. We are now beginning to see CCM and RPM companies affiliate in business models that capitalize on the natural synergies of the target populations they serve to offer a more comprehensive solution to their medical practice customers. Look for PCM to join this mix in 2020. ,
Important Requirements for Billing the PCM Codes
The Final Rule sets forth several important requirements that must be met in order to bill the PCM codes for services provided to a particular patient. Those requirements are as follows:
Billing Practitioner – The billing practitioner for both codes must be a physician or other qualified health care practitioner (QHCP). Though it is not an explicit requirement, the Centers for Medicare and Medicaid Services (“CMS”) states in the Final Rule that they expect most PCM services will be provided and billed by specialists focused on managing patients with a particular complex chronic condition that requires substantial care management. According to the Final Rule, the expected outcome of the provision of PCM services is for the patient’s condition to be stabilized by the treating specialist clinician so that overall care can be returned to the patient’s primary care practitioner.
Qualifying Condition – The Final Rule does not enumerate specific qualifying conditions for purposes of PCM, but states that PCM services will typically be triggered by exacerbation of a qualifying condition such that disease-specific care is warranted. Additionally, the Final Rule states that qualifying conditions:
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; and
Is of such complexity that it cannot be managed effectively by primary care and requires management by another, more specialized practitioner.
Not limited to patients with only one condition – The Final Rule implies that it is possible for a patient to receive PCM services from multiple specialists for multiple different conditions simultaneously (e.g. a cardiologist for arrhythmia and an endocrinologist for diabetes); however PCM services should not be furnished or billed at the same time as:
Other care management services by the same practitioner for the same beneficiary; nor
Interprofessional consultations for the same condition by the same practitioner for the same patient. Read more about How to Get Paid for Remote Interprofessional Consultations Between Physicians here.
Ongoing Communication – Ongoing communication and care coordination between all practitioners furnishing care to the beneficiary must be documented by the billing practitioner in the patient’s medical record.
General Supervision – HCPCS code G2065 allows for PCM services to be provided by clinical staff incident-to the billing physician or QHCP. These services can be provided under General Supervision, meaning the billing practitioner need not be co-located in the same office as the clinical staff member providing the services, but must be available to the clinical staff member to answer questions and intervene when necessary.
Initiating Visit – For new patients and patients not seen within a year prior to initiation of PCM, the billing practitioner must conduct an initiating visit with the patient in order to educate the patient on PCM and obtain the patient’s informed consent. This visit is can be an annual wellness visit (AWV) or other separately billable visit.
Consent – The billing practitioner must obtain the patient’s informed consent and document that consent in the patient’s medical record. Consent can be obtained verbally, but the patient should be educated as to:
What PCM services are;
That only one practitioner can bill per month for an indicated chronic condition;
The fact that the patient has the right to stop the services at the end of any service period; and
Any cost-sharing that may apply.
Concurrent Billing with RPM – PCM services can be billed in the same month or billing period as RPM services, so long as the time spent providing services under each is not counted twice. In other words, the time requirements set forth under each applicable code must be met separately in order for the services to be billable.
Disease-specific Care Plan – Under Chronic Care Management (CCM), practitioners are required to develop a comprehensive care plan in order to bill relevant CCM codes. For PCM, CMS set forth in the Final Rule that billing practitioners should instead develop a disease-specific care plan for patients receiving PCM services. A disease-specific care plan is more limited than a comprehensive care plan, focusing only on the disease or condition at issue.
Only medically reasonable and necessary elements required – Though the Final Rule provides for the requirements listed in this document, the Final Rule also states that all elements do not necessarily apply every month in order for the codes to be billed, so long as those elements that are medically reasonable and necessary are provided.
FQHCs and RHCs not eligible to bill PCM – CMS stated in the Final Rule that it will consider adding PCM to HCPCS code G0511, the modifier for care management services, in the future; however, it has not done so in the Final Rule, and therefore the PCM codes are not available to FQHCs and RHCs.
In addition to the above requirements, the Final Rule lays out in some detail the specific requirements applicable to PCM services as follows:
Nixon Law Group is a leading healthcare innovation law firm focused on providing business and legal guidance to healthcare providers, practices, and vendors across the spectrum of care. Interested in implementing PCM in your healthcare practice or expanding your CCM or remote patient monitoring offerings? Contact us!
Discover how we can help you optimize innovative payment models.