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Published August 17, 2021

Medicare Proposes New Codes and More Money for Care Management Services in 2022

Providers presently furnishing ambulatory care management services (including chronic care management and remote monitoring) for Medicare beneficiaries—as well as those considering these services—should take a careful look at the 2022 Medicare Physician Fee Schedule Proposed Rule. Specifically, the Proposed 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).
    5. Request for comment on additional reimbursement for chronic pain management.

 1. Expanded Code Set for Care Management Services

The Centers for Medicare & Medicaid Services (CMS) proposes to complete the code sets for care management services (new codes in italics):

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 99X21

Subsequent 30 minutes, physician or NPP

CCCM

CPT 99487

Initial 60 minutes, clinical staff

CPT 99489

Subsequent 30 minutes, clinical staff

 

 

PCM

CPT 99X24

(currently G2065)

Initial 30 minutes, clinical staff

CPT 99X25

Subsequent 30 minutes, clinical staff

CPT 99X22

(Currently G2064)

Initial 30 minutes, physician or NPP

CPT 99X23

Subsequent 30 minutes, physician or NPP

 

2. Increased Reimbursement for CCM, CCCM, and PCM

CMS proposes increasing the work values for the care management codes, which would result in a significant increase in Medicare reimbursement for these services in 2022. The following table lists the current 2021 national payment rate (non-facility) compared to the proposed 2022 national payment rate (non-facility) by CPT code.[2] (PYA’s Providing and Billing Medicare for Chronic Care Management Services provides a complete explanation of Medicare billing rules for care management services.) 

Code

Descriptor

2021 Payment

2022 Proposed Payment

Difference

99490

CCM, clinical staff, initial 20 min

$41.17

$63.47

+$22.30

99439

CCM, clinical staff, +20 min

$37.69

$49.36

+$11.67

99491

CCM, physician/NPP, 30 min

$82.53

$84.29

+$1.76

99X21

CCM, physician/NPP, +30 min

n/a

$60.11

n/a

99487

CCCM, clinical staff, 60 min

$91.77

$138.35

+$46.58

99489

CCCM, clinical staff, +30 min

$43.97

$71.86

+$27.89

99X22

PCM, physician/NPP, 30 min

$90.37

$81.60

-$8.77

99X23

PCM, physician/NPP, +30 min

n/a

$59.44

n/a

99X24

PCM, clinical staff, 30 min

$38.73

$63.13

+24.40

99X25

PCM, clinical staff, +30 min

n/a

$65.24

n/a

G0511

Care management, RHC/FQHC*

$65.24

$81.93

$16.70

*Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC)

3. RPM Reimbursement

CMS proposes minor changes in RPM reimbursement, with the exception of CPT 99454, which would see a significant reduction.

Code

Descriptor

2021 Payment

2022 Proposed Payment

Difference

99453

Service initiation

$19.19

$22.16

+$2.97

99454

Monthly data transmission

$63.16

$49.36

-$13.80

99091

Interpretation and analysis, 30 min

$56.88

$54.06

-$2.82

99457

Treatment management services, clinical staff, 20 min

$50.94

$51.71

+$0.77

99458

Treatment management services, clinical staff, +20 min

$41.17

$40.97

-$0.20

 

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 proposed 20% reduction in reimbursement, it will be even more challenging to make RPM programs work financially. 

Presently, treatment management services (CPT 99457 and 99458) are reimbursed at a higher rate than CCM services. If CMS’ proposal is finalized, however, CCM services will be reimbursed at a significantly higher rate, meaning many providers furnishing RPM services will consider restructuring their programs to accommodate billing for CCM services in lieu of treatment management services.       

4. Remote Therapeutic Monitoring

Other than the changes to reimbursement, the Proposed Rule is silent on the subject of RPM, despite continued questions regarding these services. (PYA’s Providing and Billing Medicare for Remote Patient Monitoring and Treatment Management offers a summary of issues.) Instead, CMS proposes new reimbursement for remote therapeutic monitoring (RTM) services. This includes the following suite of codes created by the American Medical Association (AMA) in October 2020 and valued by its RVS Update Committee in January 2021:

Code

Descriptor

2022 Proposed Payment

989X1

Service initiation

$22.50

989X2

Monthly data transmission – respiratory system

$45.00

989X3

Monthly data transmission – musculoskeletal system

$45.00

989X4

Treatment management services, clinical staff, 20 min

$51.38

989X5

Treatment management services, clinical staff, +20 min

$41.30

 

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). And unlike RPM, RTM does not require a minimum 16 days of data be collected and reported over a 30-day period. 

The most obvious use case for RTM is medication adherence for respiratory or musculoskeletal conditions (as reimbursement for monthly data transmission is limited to these two systems). 

The AMA included the RTM codes under the general medicine codes rather than the evaluation and management codes (which is where the RPM codes are listed). As CMS notes in the Proposed Rule, this creates issues regarding who can bill for these services and whether RTM treatment management services may be performed by clinical staff incident to the billing practitioner’s services. CMS seeks comment regarding the resolution of these issues.   

5. Chronic Pain Management

Finally, CMS seeks comment on whether Medicare should provide additional reimbursement to incentivize providers to furnish care management services for beneficiaries with chronic pain. Noting that chronic pain management “could potentially be effective in preventing or reducing the need for acute services…and reduce the need for treatment for mental disorders,” CMS acknowledges that “[c]urrent Medicare payment methodologies such as [CCM] support chronic disease management, though may not provide adequate payment to health care providers or systems to holistically care for beneficiaries with chronic pain; we believe the complexity and resources required for safe and effective pain management may not be adequately captured and paid through these codes.” 

Comments

Any interested person or entity may submit comments regarding any provision in the Proposed Rule. CMS is required by law to consider and respond to all relevant comments in drafting the Final Rule, which will be published in November or December. Comments are due September 13, 2021, and may be submitted electronically through https://www.regulations.gov/.

If your organization seeks assistance with comment submittal or evaluating the effects of these proposed changes, contact a PYA executive below at (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 proposes reimbursement for 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 relative value units (RVU) listed in Addendum B to the Proposed Rule by the proposed 2022 conversion factor of $33.58 (which represents a 3.75% reduction from the 2021 conversion factor).

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