CMS proposes payment for advanced primary care management services

On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the Medicare Physician Fee Schedule (MPFS) 2025 proposed rule (the Proposed Rule), which includes proposed new advanced primary care management (APCM) billing codes that would expand opportunities for physician practices, federally qualified health centers (FQHCs), rural health clinics (RHCs) and other health care providers to get paid for services provided by clinical staff under the direction of a physician, nurse practitioner or physician assistant.

The proposed new APCM billing codes incorporate elements based on current CPT codes for chronic care monitoring (CCM), transitional care management (TCM), and principal care management (PCM) and would be divided into three levels based on the number of chronic conditions and whether the beneficiary is enrolled as a Qualified Medicare Beneficiary.  All three of these G codes would apply to APCM services provided by clinical staff and directed by a physician or other qualified health care professional, such as a nurse practitioner or physician assistant, who is responsible for all primary care and serves as the continuing focal point for all needed health care services. Unlike CCM and PCM, the proposed APCM codes do not include a time threshold. These proposed placeholder codes, which are expected to replaced with numeric G codes if and when finalized, and approximate monthly national payment amounts are:

• GPCM1 (Level 1): APCM services for a patient with no more than one chronic condition ($10)
• GPCM2 (Level 2): APCM services for a patient with multiple chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline ($50)
• GPCM3 (Level 3): APCM services for a patient who is a Qualified Medicare Beneficiary with multiple chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline ($110).

The Proposed Rule sets forth the following required APCM service elements and capabilities for all three APCM codes:

• Beneficiary consent must be obtained and documented in the medical record. The beneficiary must be informed that APCM services are available, that only one practitioner can furnish and be paid for these services during a calendar month, that the beneficiary has the right to stop services at any time (effective at the end of the calendar month), and that cost sharing may apply. The Proposed Rule adds that the practitioner should also inform the beneficiary that the practitioner intends to assume responsibility for all of the patient’s primary care services and serve as the continuing focal point for all needed health care services, but that the consent does not limit the patient’s option to receive Medicare covered health care services from other practitioners
• An initiating visit will be required unless either the beneficiary has been seen by the practitioner or another practitioner in the same practice within the past three years, or the beneficiary received another care management service (such as APCM, CCM, or PCM) within the previous year from the practitioner or another practitioner in the same practice.
• The practice must provide 24/7 access to the care team or practitioner to discuss urgent care needs, must have the capability to deliver care outside normal office visits (such as e-visits, phone visits, home visits, and/or expanded hours), and must offer continuity of care with a designated member of the care team with whom the patient can schedule successive routine appointments.
• The practice must provide overall comprehensive care management, such as systematic assessment of medical, functional, and psychosocial needs, system-based approaches to ensure timely receipt of all recommended preventive care services, medication reconciliation with review of adherence and potential interactions, and oversight of patient self-management of medications.
• An electronic patient-centered comprehensive care plan needs to be maintained and updated, must be timely available within and outside the practice to individuals involved in the beneficiary’s care, and a copy must be provided to the patient or caregiver. CMS expressed the expectation that a care plan will outline the patient’s health goals, needs, and self- management activities and will be patient-friendly and accessible to the patient.
• The practice needs to manage care transitions. This element includes coordination of care transitions between and among health care providers and settings, follow-up after an emergency department visit or discharge from a health care facility, timely exchange of electronic health information, and follow-up communication with the patient or caregiver after within 7 days of discharge, as clinically indicated.
• The practice needs to provide ongoing communication and coordination of services of practitioners, home-based and community based service providers, community-based social service providers, hospitals, skilled nursing facilities and other facilities, as well as medical record documentation of communication regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors.
• The beneficiary and any caregiver must have the opportunity for ongoing communication with the care team or practitioner through asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, and other communication technology-based services. The practice needs to ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and E/M visits (or e-visits).
• The patient population-level management element involves population-based, data-driven approaches to manage preventive and chronic care and implement strategies to improve care and outcomes. The practice is required to analyze patient population data to identify gaps in care and offer additional interventions as appropriate, and to stratify risk of the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients. Participation in a Shared Savings Program ACO, REACH ACO, Making Care Primary, or Primary Care First would satisfy this element.
• Performance needs to be measured for primary care quality, total cost of care, and meaningful use of certified electronic health record technology (CEHRT). A MIPS-eligible clinician can register for and report the Value in Primary Care MVP. A practitioner who is part of a Tax Identification Number (TIN) participating in a Shared Savings Program ACO would satisfy this requirement through the ACO’s reporting of the APM Performance Pathway. A practitioner who is participating in a Shared Savings Program ACO, REACH ACO, Making Care Primary, or Primary Care First would satisfy this requirement through the quality reporting, assessment and performance requirement and other program and model requirements.

CMS has identified services and related billing codes that overlap substantially with APCM services and therefore are not allowed to be billed in the same period as APCM by the same practitioner or another practitioner within the same practice for the same patient. These “duplicative” services include CCM, PCM, TCM, and 15 communication-based technology CPT codes for inter-professional consultation, remote evaluation of patient videos/images, virtual check-in, and e-visits.

In contrast, CMS identified other care management services as potentially complementing, rather than overlapping or duplicating, APCM, including behavioral health integration (BHI), services addressing health-related social needs (HRSNs), remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM), so CMS will allow concurrent billing of those services and APCM when appropriate.

CMS proposes extending APCM billing codes to FQHCs and RHCs. CMS is also proposing that FQHCs and RHCs bill care management and related services, such as CCM, PCM and TCM, as well as RPM and RTM, under CPT billing codes, rather than the HCPCS general care management code G0511.

CMS requested comments on the proposed payment amounts and related services, definitions and costs. The comment period for the MPFS 2025 Proposed Rule ends September 9, 2024.

For more information on the MPFS 2025 Proposed Rule or care management services, please contact attorney Rick Hindmand.