Care management, behavioral health featured in final 2017 fee schedule

by DecisionHealth Staff on Nov 3, 2016

You’ll find new opportunities to code for services related to care management and behavioral health in 2017, according to the final 2017 Medicare physician fee schedule released Nov. 2. CMS finalized a suite of HCPCS codes for physician-led behavioral health services, two complex chronic care management (CCM) codes, initiating visit codes and more.

Here’s a rundown of the new codes and services:

  • Three HCPCS codes tied to the Collaborative Care Model. They are G0502G0503 and G0504, which involve “psychiatric collaborative care management” between a supervising physician, a behavioral health care manager and a consulting psychiatrist. G0502 requires 70 minutes for the first month; G0503 requires 60 minutes in subsequent months; and G0504 is a 30-minute add-on code.
  • One general behavioral health intervention code. That’s G0507, which covers 20 minutes of “care management services for behavioral health conditions” per month. Similar to CCM code 99490, the care management under G0507 can be performed by clinical staff and does not require on-site staff.
  • Complex CCM codes – 99487 and 99489. These are essentially beefed up CCM codes. The complex CCM variety require the same service elements as their little brother 99490 but “differ in the amount of clinical staff service time provided; the complexity of medical decision-making … and the nature of care planning that was performed.”
  • Initiating visit add-on code for CCM services. A face-to-face initiating visit “is required before CCM services can be provided,” states the final rule. Now providers have a way to bill – using add-on code G0506 – for “additional work of the billing practitioner in personally performing a face-to-face assessment” ahead of a CCM episode.

You’ll also find relaxed billing rules for CCM services in 2017, which include getting rid of a beneficiary consent form and removing the requirement for 24/7 access to care. “We are finalizing revisions to the CCM scope of service elements as proposed,” states the final rule.

More key pieces to the rule:

  • Higher conversion factors. CMS estimates that the conversion factor will increase to $35.8887 from this year’s $35.8043. That’s a small boost from the proposed rule, which estimated the CF at $35.7751. For anesthesia providers, CMS estimates a $22.0454 conversion factor, up from this year’s $21.9935 and from the proposed rule’s $21.9756.
  • Scaled-back global period data collection program. In response to pressure from physician societies and members of Congress, CMS says it will require data reporting only from practices of 10 or more practitioners in nine states (Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon and Rhode Island).

Practitioners in those states will be required to report CPT code 99024 (Postoperative follow-up visit) for their post-operative services provided during 10- and 90-day global periods. However, reporting will be required for only high-volume or high-dollar procedures – that is, those codes reported more than 10,000 times or with allowed charges of more than $10 million annually. Physicians in smaller practices and/or other states can participate voluntarily, the agency states.

CMS says it will issue a list of the codes for which it will require global period reporting on its website. The list, to be based on CY 2014 claims data, is likely to consist of about 260 codes that account for 87% of the global period codes doctors provide and about 77% of Medicare expenditures for the global procedures.

CMS will encourage participants to begin reporting starting Jan. 1, but the requirement to report will take effect July 1. The finalized global reporting program is a big step back from the proposed version, which would have required all physicians to report a set of unpaid, time-based G codes for services provided during all their 10- and 90-day global periods for the entire year.

  • One more moderate sedation code. In addition to the six new moderate sedation codes issued in CPT 2017, providers will use G0500 when they provide moderate sedation for certain gastrointestinal endoscopy procedures. The code’s full descriptor is “moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service (excluding biliary procedures) that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate).”

Table 26 of the rule lists all of the codes that were revalued because of the removal of the moderate sedation relative value units (RVUs). Services that should be reported with G0500 are marked with a Y. “My thought is they will be tracking sedation services to compare how many procedures are done with surgeon sedation versus those billed separately by anesthesia providers. They could be doing this in order to make a recommendation about the base unit value of 00810 [Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum],” said Devona Slater, CHC, CHA, CMCP, president, Auditing for Compliance & Education, Overland Park, Kan.

  • Payment for non-face-to-face prolonged services. CMS is making good on a proposal to allow separate payments for 99358 (Prolonged evaluation and management service before and/or after direct patient care; first hour) and 99359 (Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes [List separately in addition to code for prolonged service]). Those codes were previously bundled with other E/M codes.

A major provider objection to Medicare’s handling of this has been removed: In July, CMS proposed that those codes would have to be furnished on the same day by the same provider as the companion E/M code to be paid. CMS now says this was a “drafting error.” Medicare will stick with the CPT guidance: The codes describe services “furnished during a single day directly related to a discrete face-to-face service that may be provided on a different day, provided that the services are directly related to those furnished in a face-to-face visit.”

As to the proposal that prolonged service codes not be allowed with complex CCM services (99487and 99489) and transitional care management (TCM) services (99495 and 99496), CMS mostly held its ground; complex CCM “cannot be reported during the same month as non-face-to-face prolonged services,” while prolonged services “cannot be reported during the TCM 30-day service period by the same practitioner who is reporting the TCM” – which suggests that another provider could bill.

Also, CMS will allow the new code G0505 (Cognition and functional assessment by the physician or other qualified health care professional in office or other outpatient) to be billed as an “associated companion code, whether furnished on the same day or a different day” to 99358 and 99359. But they cannot be billed with the new add-on code G0506.

  • New Medicare Diabetes Prevention Program (MDPP). The proposed model – in which providers could be paid for months and even years of non-medical counseling of beneficiaries – has been finalized more or less in its original state. Enrolled providers and suppliers may offer the service, and the “coaches” who give it need not be enrolled providers, though they will need national provider identifier (NPI) numbers.

But CMS expanded the rules to allow additional months of maintenance sessions even if patients haven’t met a weight-loss target.

Also, beneficiaries won’t have co-pays for their sessions. The program will officially start on Jan. 1, 2018. Providers and suppliers are still required to meet CDC standards for the program, which require a year of run-up before they can bill Medicare; a proposal to allow “preliminary recognition” has been rejected. But CMS says they “intend to address this issue in future rulemaking.”

  • Provider enrollment for Medicare Advantage. As proposed, CMS will require providers and suppliers to be screened and enrolled in Medicare before they can contract with a Medicare Advantage organization to provide items and services to Medicare Advantage health plan beneficiaries. The requirement takes effect two years after the final rule is published.

Also as proposed, data generated when Medicare Advantage organizations (MAOs) submit bids to CMS that reflect their estimated costs of providing benefits to enrollees – known as bid data – will be made public on an annual basis, as will the MAOs’ medical loss ratio (MLR) data, which shows how successfully MAOs comply with the Affordable Care Act requirement that at least 85% of plan revenues be attributed to claims and quality improvement activities as opposed to such things as overhead and marketing.

  • Fluoroscopy work RVUs won’t change. Medicare had proposed a cut to the RVUs for needle guidance codes 77002 and 77003, which will be reported as add-on codes in 2017. Under the proposal, both codes would have been assigned 0.38 work RVUs, bringing them in line with central venous guidance code 77001. Based on comments that explained the additional work required for the two needle guidance codes, Medicare will leave them at 0.54 for 77002 and 0.60 for 77003.
  • A small set of revisions to the Stark self-referral list. Most of the revisions to the list of codes that are included or excluded from the definition of a designated health service (DHS) under the Stark physician self-referral rule are simple swaps; codes that will be deleted were replaced with the new codes. However, Medicare did add 77063 (Screening digital breast tomosynthesis, bilateral [List separately in addition to code for primary procedure]) to the list of codes that are excluded from the definition of DHS in response to a commenter’s request.

Stay tuned to your DecisionHealth publication for more details.

To read the rule, visit

To learn about the moderate sedation changes, register for the Nov. 17 webinar Moderate sedation services – New codes, new rules and new payments in 2017.

To learn about the key pieces of the rule in one hour, register for the Nov. 22 webinar 2017 Physician Fee Schedule: Capture new revenue, understand code changes and more.

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