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2022 Medicare Physician Fee Schedule Final Rule: Increased Reimbursement for Care Management Services
Published November 8, 2021

2022 Medicare Physician Fee Schedule Final Rule: Increased Reimbursement for Care Management Services

Published on November 2, 2021, the 2,414-page 2022 Medicare Physician Fee Schedule Final Rule includes good news for providers presently furnishing care management services for Medicare beneficiaries and gives good reason for those providers not doing so to re-evaluate the opportunity. The news regarding remote patient monitoring services is more mixed.

Specifically, the Final Rule includes:  

  1. An expanded code set for care management services–chronic care management (CCM), complex chronic care management (CCCM), and principal care management (PCM) services
  2. A significant increase in reimbursement for CCM, CCCM, and PCM services
  3. A significant decrease in reimbursement for data transmission associated with remote physiologic monitoring (RPM) (CPT 99454)[1]
  4. New reimbursement for remote therapeutic monitoring (RTM)

 

  1. Expanded Code Set for Care Management Services

For 2022, the Centers for Medicare & Medicaid Services (CMS) is completing the code sets for care management services (new codes in italics):

Chronic Care Management (CCM)

CPT 99490

Initial 20 minutes, clinical staff

CPT 99439

Subsequent 20 minutes, clinical staff

CPT 99491

Initial 30 minutes, physician or non-physician practitioner (NPP)

CPT 99437

Subsequent 30 minutes, physician or NPP

 

Complex Chronic Care Management (Complex CCM)

CPT 99487

Initial 60 minutes, clinical staff

CPT 99489

Subsequent 30 minutes, clinical staff

 

 

 

Principal Care Management (PCM)

CPT 99426

(previously G2065)

Initial 30 minutes, clinical staff

CPT 99427

Subsequent 30 minutes, clinical staff

CPT 99424

(previously G2064)

Initial 30 minutes, physician or NPP

 

CPT 99425

Subsequent 30 minutes, physician or NPP

 

  1. Increased Reimbursement for CCM, Complex CCM, and PCM

The 2022 conversion factor—the dollar amount by which the assigned relative value units (RVUs) for a specific service is multiplied to determine the Medicare national payment amount for that service—is $33.60, down from $34.89 in 2021. Thus, Medicare reimbursement for most services in 2022 will be about 4% less than in 2021.

For care management services, however, CMS is adopting the American Medical Association (AMA) RVU Update Committee’s (RUC) recommended increases in the assigned relative value units. As a result, there will be significant increases in Medicare reimbursement for these services in 2022. 

The following table lists the current 2021 national payment rate (non-facility) compared to the 2022 national payment rate (non-facility) by CPT code.[2] (Please see PYA’s Providing and Billing Medicare for Chronic Care Management Services for a complete explanation of Medicare billing rules for care management services.) 

Code

Descriptor

2021 Payment

2022 Payment

Difference

99490

CCM, clinical staff, initial 20 min.

$41.17

$62.16

+$20.99

 

99439

CCM, clinical staff, +20 min.

$37.69

$47.04

+$9.35

 

99491

CCM, physician/NPP, 30 min.

$82.53

$83.66

+$1.13

 

99437

CCM, physician/NPP, +30 min.

n/a

$59.47

n/a

 

99487

Complex CCM, clinical staff, 60 min.

$91.77

$130.37

+$38.60

 

99489

Complex CCM, clinical staff, +30 min.

$43.97

$68.51

+$24.54

 

99424

PCM, physician/NPP, 30 min.

$90.37

$80.98

-$9.39

 

99425

PCM, physician/NPP, +30 min.

n/a

$58.46

n/a

 

99426

PCM, clinical staff, 30 min.

$38.73

$61.49

+22.76

 

99427

PCM, clinical staff, +30 min.

n/a

$47.04

n/a

 

G0511

Care mgt., RHC/FQHC*

$65.24

$76.94

+$11.70

 

*RHC is a rural health clinic and FQHC is a Federally Qualified Health Center

Note that 2022 reimbursement for CPT 99487 (Complex CCM), which requires 60 minutes of care management services furnished by clinical staff, is $25.87 less than reimbursement for one unit of CPT 99490, plus two units of 99439 (totaling 60 minutes of care management services). Billing for Complex CCM, therefore, will likely be a thing of the past, given the additional requirements associated with it (e.g., moderate- to high-complexity medical decision-making).

  1. RPM Reimbursement

By contrast, CMS’ adjustments to the assigned RVUs for the RPM codes result in small decreases in reimbursement for four of the fives codes. For CPT 99454 (monthly data transmission), however, the reduction is significant:   

Code

Descriptor

2021 Payment

 

2022 Payment

Difference

99453

Service initiation

$19.19

$18.48

-$0.71

 

99454

Monthly data transmission

$63.16

$54.10

-$9.06

 

99091

Interpretation and analysis, 30 min.

$56.88

$54.77

-$2.11

 

99457

Treatment management services, clinical staff, 20 min.

 

$50.94

$48.72

-$2.22

99458

Treatment management services, clinical staff, +20 min.

 

$41.17

$39.65

-$1.52

Many had complained previously that the monthly reimbursement for data transmission was too low to cover the costs of providing RPM services. Now, with a nearly 15% reduction in reimbursement, it will be even more challenging to make RPM programs work financially. 

Since CMS introduced reimbursement for treatment management services (CPT 99457 and 99458), these services have been reimbursed at a higher rate than CCM services. Beginning in 2022, CCM services will be reimbursed at a significantly higher rate, meaning clinical providers furnishing RPM services should consider re-structuring their programs to accommodate providing and billing for CCM services in lieu of treatment management services.   

Other than the changes to reimbursement, the Final Rule is silent on the subject of RPM, despite continued questions regarding these services. (Please see PYA’s Providing and Billing Medicare for Remote Patient Monitoring and Treatment Management for a summary of issues.)  

  1. Remote Therapeutic Monitoring

CMS is introducing new reimbursement for remote therapeutic monitoring (RTM) services in 2022. This includes the following suite of codes created by the AMA in October 2020, and valued by its RUC in January 2021:

 

Code

Descriptor

 

2022 Payment

98975

Service initiation

$18.82

 

98976

Monthly data transmission–respiratory system

$54.10

 

98977

Monthly data transmission–musculoskeletal system

$54.10

 

98980

Treatment management services, clinical staff, 20 min.

$48.72

 

98981

Treatment management services, clinical staff, +20 min.

$39.65

 

Unlike RPM, RTM involves non-physiologic data, which can be self-reported by the patient to the billing practitioner (as opposed to requiring the data be transmitted automatically by the device). The most obvious use case for RTM is medication adherence and/or response for respiratory or musculoskeletal conditions (as presently reimbursement for monthly data transmission is limited to these two systems). 

Unlike their RPM counterparts, the RTM codes are general medicine codes, meaning they can be billed by providers who cannot bill for evaluation and management codes. While CMS permits therapists and other qualified healthcare professionals to bill the RTM codes, the agency notes that “where the practitioner’s Medicare benefit does not include services furnished incident to their professional services, the items and services described by these codes must be furnished directly by the billing practitioner or, in the case of a PT [physical therapist] or OT [occupational therapist], by a therapy assistant under the PT’s or OT’s supervision.”    

Also, CMS has not included CPT 98980 and 98981 as designated care management services assigned to general supervision. Thus, a physician or non-physician practitioner billing for these services must provide direct supervision (i.e., physical presence) for the clinic staff furnishing these services.

If you would like additional guidance related to the 2022 Medicare Physician Fee Schedule Final Rule, or for assistance with any matter related to compliance, valuation, or strategy and integration, one of our executive contacts would be happy to assist. You may email them below, or call (800) 270-9629.

 

[1] The acronym “RPM” often refers to remote patient monitoring, which is a generic term. Remote physiologic monitoring is the service for which Medicare presently provides reimbursement. Remote therapeutic monitoring is a distinct service with different requirements for which CMS will begin reimbursing in 2022. Both remote physiologic monitoring and remote therapeutic monitoring are types of remote patient monitoring.    

[2] The 2021 rates were retrieved from the Medicare Physician Fee Schedule Look-Up Tool. The 2022 rates were calculated by multiplying the total Non-Facility RVUs listed in Addendum B to the Final Rule by the 2022 conversion factor of $33.60. 

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