CMS focuses on behavioral health, CCM in proposed fee schedule

Say hello to a new batch of G codes, newly reimbursable CPT codes and revised chronic care management (CCM) reporting criteria as CMS attempts to better capture the work a provider performs behind the scenes when treating episodic care.

 

Starting in 2017, Medicare proposes to cover several behavioral health-related services under temporary G codes, according to the proposed 2017 Medicare physician fee schedule released July 7. The new behavioral health-related codes include:

·  GPPP1 (Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional),

·  GPPP2 (Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional) and

·  GPPP3 (Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional).

CMS proposes to cover at least four additional G codes for behavioral health-related services, including codes related to cognitive impairment.

 

Get ready to add additional CCM codes to your arsenal. CMS says it will cover current CPT codes 99487 and 99489 for complex chronic care management starting in 2017 “to more appropriately recognize and pay for the other codes in the CPT family of CCM services,” according to the proposed rule.

Medicare will also recognize non-face-to-face prolonged service codes 99358 and 99359 in 2017.

 

·  Lower the conversion factors. CMS proposes a $35.7751 conversion factor, down from the current $35.8043. The proposed figure reflects the budget neutrality adjustment, 0.5% update specified in MACRA and a non-budget-neutral 5% multiple procedure payment reduction (MPPR) for the professional component of imaging services, the rule states. For anesthesia providers, CMS proposes a $21.9756 conversion factor, down from this year’s $21.9935.

·  Start global period data collection. CMS proposes to launch a claims-based data collection effort as well as a survey of 5,000 practitioners to amass data on activities and resources they provide during 10- and 90-day surgical global periods. The global period data collection was mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and may result in revaluation of surgical services in future rulemaking.

·  Add 83 high-volume, zero-day global codes to “potentially misvalued” list. CMS has identified 83 zero-day global period codes that providers are billing with E/M visits on a frequent basis, even though modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) “should only be used for reporting services beyond those usually provided.” So the agency will propose to prioritize the services for review as misvalued.

·  Cut the pay for the technical component (TC) of X-rays taken using film by 20% starting Jan. 1. The agency is proposing that providers append new modifier XX to identify those services. The cut is required by the Consolidated Appropriations Act of 2016, which also mandates a 7% reduction in pay for imaging services that are X-rays taken using computed radiology furnished during calendar years 2018, 2019, 2020, 2021 or 2022. The act also calls for a 10% reduction for such imaging services taken using computed radiology furnished during 2023 or a subsequent year. The X-ray component of a packaged service is included in those cuts.

·  Add new codes. The “valuation of specific codes” section gives you hint of the codes you’ll use in 2017 as CMS discusses the valuation for new codes for such services as dialysis circuit, epidural injections and moderate sedation.

·  Overhaul moderate sedation. CMS, working in conjunction with CPT, will revamp the way you are paid for moderate sedation services and services that include moderate sedation as part of the procedure – the codes listed in Appendix G of your CPT manual. In addition to six new CPT codes and one new endoscopy-specific HCPCS code, CMS intends to create “a uniform methodology for valuation of the procedural codes that currently include moderate sedation as an inherent part of the procedure,” the rule states.

·  Add advance care planning codes 99497 and 99498 to the list of approved telehealth services. CMS did not receive a request to add the codes but “determined that these services are similar” to annual wellness visit codes G0438 and G0439 that are already on the telehealth list.

·  Encourage diabetes outreach. CMS is expanding the Innovation Center’s Diabetes Prevention Program. “The second CMS Innovation Center – and first preventive services – model that has been certified for expansion,” it consists of non-physician, community-based organizations that educate pre-diabetic Medicare beneficiaries in a “classroom” environment on lifestyle changes. CMS proposes a payment structure based partially on patient weight targets and would require organizations providing this education to have national provider identification (NPI) numbers and to submit standard Medicare claims.

Also, CMS notes with apparent alarm a study showing “only 5% of Medicare beneficiaries with newly diagnosed diabetes used DSMT [diabetes self-management training] services” and says manual updates are coming that should help, such as one allowing practice providers to furnish DSMT services at “alternate locations used by the entity as a practice location.”

·  Revise Medicare Advantage provider enrollment. Perhaps motivated by recent Congressional hearings on Medicare Advantage overspending and possible fraud and saying they want MA beneficiaries to have “the same protections against potentially unqualified or fraudulent providers and suppliers” as fee-for-service beneficiaries, CMS wants to require all providers and suppliers involved in Medicare Advantage services – including HMOs, Program of All-inclusive Care for the Elderly (PACE) and other organizations – to be enrolled in Medicare “in an approved status.” CMS is also creating new Medicare Advantage data sets, including bid pricing and minimum loss ratio (MLR) information, to assist policy-making and consumer choice, and new statutory language putting MA organizations under tighter control by CMS. For example, the rule would give the agency “the authority to impose sanctions if an MA organization or PACE organization fails to meet provider and supplier enrollment requirements,” the rule states.

 

The proposed rule is available here until it’s published in the Federal Register on July 15. CMS will accept comments until Sept. 6.