The Centers for Medicare and Medicaid Services (CMS) has approved two new Principal Care Management (PCM) CPT codes for 2020 that may apply to allergists treating patients with severe uncontrolled asthma. The new codes provide additional monthly payments above existing E/M codes. They may be an additional revenue opportunity for allergists caring for patients with severe, high-risk asthma who meet required criteria. This is a win-win for both allergists and patients. CMS’ goal is to improve care for these complicated patients and keep them out of the emergency room and hospital, and it is willing to pay physicians more to make that happen. Here are the details:
1. PCM codes are intended to cover services for patients with only one complex chronic condition that requires management by a specialist. Like other chronic care management (CCM) codes (chronic care management, transitional care management), the PCM codes are intended to reimburse physicians for the additional work they do caring for high risk, complex patients. This includes the extra time and work required for medication adjustments, creating a care plan, patient follow-up and more.
2. There are two PCM codes:
- G2064 requires 30 minutes of provider (allergist, NP, PA) time each calendar month to care for the patient. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $52/patient/month.
- G2065 requires 30 minutes of clinical staff time directed by a provider each calendar month for patient care. Provider supervision does not require the provider to be onsite while clinical staff performs PCM services. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $22/patient/month.
The 30 minutes of provider/clinical staff time does not have to be face-to-face time, but can be time used to create care plans, follow up with patients via phone, etc.
3. Patients covered by PCM codes must meet the following criteria defined by CMS:
- They have one complex chronic condition lasting at least three months.
- The condition is severe enough that the patient is at risk for hospitalization or was recently hospitalized due to the condition.
- The condition requires development or revision of a 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.
4. There are two potential barriers to using PCM codes:
- Patients must consent to receive this service.
- Patients are responsible for the 20% beneficiary cost-sharing requirement for CCM services. (However, the Chronic Care Management Improvement Act currently in Congress would eliminate the 20% beneficiary cost-sharing requirement for CCM services. If passed, Medicare would pay 100% of the service costs for CCM.)
Allergy practices would need to develop ways to carefully communicate these requirements to patients to make them viable.
5. Specialists using PCM codes are not required to assume complete care of the patient for other, unrelated diagnoses, although co-morbidities should be taken into consideration during treatment.
6. The requirements for PCM codes are very specific and easily audited. Allergists billing PCM codes need to carefully document that patients meet the above criteria. The disease-specific care plan should be included in the patient’s chart, along with documentation of medication adjustments, patient communications, etc. Finally, allergy practices should document the amount of time spent providing care each month.
Neither private payers or Medicaid are obligated to pay these codes. Providers need to check with the payer or state Medicaid program to verify coverage. Medicare Advantage plans would cover and reimburse these codes.
Here’s more detail from CMS about PCM codes:
| HCPCS: | G2064 |
|---|---|
| Descriptor: | 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 three 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 a disease-specific care plan; the condition requires frequent adjustments in the medication regimen, and/or management of the condition is unusually complex due to comorbidities. |
| Final CY 2020 Work RVU: | 1.45 |
| 2020 Estimated Reimbursement Per Patient Per Month: | $52 |
| HCPCS: | G2065 |
|---|---|
| Descriptor: | Comprehensive care management services for a single high-risk disease, e.g. Principal Care Management; at least 30 minutes per calendar month of clinical staff time directed by a physician or other qualified health care professional with the following elements: one complex chronic condition lasting at least three 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 new adjustments in the medication regimen; and/or the management of the condition is unusually complex due to comorbidities. |
| Final CY 2020 Work RVU: | 0.61 |
| 2020 Estimated Reimbursement Per Patient Per Month: | $22 |
PCM codes represent the first-time allergists are really eligible to participate in CMS’ care management program. Review the requirements carefully to determine whether your practice can benefit from this program.
