Get the Scoop on Proposed Medicare Codes for Managing 1 Chronic Condition

code for principal care management

You’ve got Chronic Care Management (CCM) codes when a patient has multiple chronic conditions to manage, but what about when there’s just one? To help solve the problem, Medicare wants to introduce new codes for Principal Care Management (PCM). Here’s more on that from the 2020 Medicare Physician Fee Schedule (MPFS) proposed rule.

Start With the Proposed Principal Care Management Codes

The proposed codes do not have final characters or descriptors yet, but they are temporarily identified as follows. The only difference in the descriptors is which healthcare professional is involved (bold added for easy identification):

  • GPPP1 (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)
  • GPPP2 (Comprehensive care management for a single high-risk disease services, 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 patient at risk of hospitalization or have been 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).

Understand Timing and Severity Elements in PCM Codes

The descriptors are a lot to take in at once, so let’s look at some of the elements involved and what the MPFS proposed rule has to add.

The descriptors refer to a complex chronic condition lasting at least three months. The MPFS proposed rule expands on that, stating the condition “would typically be expected to last between three months and a year, or until the death of the patient.”

The descriptor goes on to include the element that the chronic condition is severe enough to put the patient at risk of hospitalization or to have caused a recent hospitalization. The MPFS proposed rule adds that the severity may place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.

Know Expectations for PCM Provider Type

The next elements listed in the code descriptors are that “the condition requires development or revision of disease-specific care plan” and frequent medication adjustments may be needed. Generally, an exacerbation or hospitalization would be the trigger for beginning PCM.

In particular, watch for a condition so complex it can’t be managed in the primary care setting. Medicare doesn’t propose to restrict which specialties may bill PCM services, but the proposed rule indicates that the expectation is that the typical billing professional would be a specialist “focused on managing patients with a single complex chronic condition requiring substantial care management.” The goal of PCM, the MPFS proposed rule states, is for the patient’s condition to be stabilized so that overall care management for the patient’s condition can be returned to the primary care practitioner.

But check this out: Remember that Medicare does not plan to limit PCM reporting to certain specialties. The MPFS proposed rule states, “If the beneficiary only has one complex chronic condition that is overseen by the primary care practitioner, then the primary care practitioner would also be able to bill for PCM services.”

Don’t Count Out Patients With More Than 1 Chronic Condition

Considering the codes represent care of a single, high-risk disease, you may wonder how to interpret the final element in the code descriptors, “the management of the condition is unusually complex due to comorbidities.”

The MPFS proposed rule offers some help there by acknowledging that many patients may have more than one complex chronic condition. Here’s how that might look:

  • There may be a clinician providing PCM services for one complex chronic condition while the primary care provider continues to manage the patient’s other conditions
  • The patient also may receive PCM services from more than one clinician “if the patient experiences an exacerbation of more than one complex chronic condition simultaneously.”

Get a Sense of Payment and Remaining Questions

Medicare plans to pay for these PCM services in 2020. Assuming the proposed codes and fees make it into the final rule, the proposed work relative value units (RVUs) for GPPP1 is 1.28 and for GPPP2 is 0.61. For work RVUs, that makes GPPP1 similar to observation discharge code 99217 and GPPP2 similar to clinical staff non-complex CCM code 99490.

There are plenty of questions Medicare is still considering. Here are a few:

  • Should there be an add-on code for additional time spent?
  • Are there ways to ensure this new PCM payment won’t lead to unnecessarily fragmented care with separate physicians taking on care for separate conditions?
  • Should PCM share the same scope of service requirements as CCM? (Expect to see rules requiring documentation of the patient’s verbal consent and knowledge of cost sharing.)
  • Which services overlap with PCM, requiring restrictions on reporting?

What About You?

Do you expect that you’ll be reporting these Principal Care Management codes if they’re adopted? Do you think the requirements are clear enough to be confident in your coding? Tip: You can learn more about the 2020 MPFS proposed rule in this blog post.

 

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

, , , , ,

Leave a Reply