DocsInk submits comments to the Center for Medicare and Medicaid Services (CMS) request for feedback regarding their proposed 2018 Physician Fee Schedule (PFS), specifically regarding the CCM program.

In response to the Center for Medicare and Medicaid Services (CMS) request for feedback regarding their proposed 2018 Physician Fee Schedule (PFS), DocsInk, LLC would like to submit the following comments for consideration and clarification.

  • 1) Gathered feedback from our clinicians around the country supports the fact that a large portion of eligible Medicare beneficiaries continue to opt-out of the CCM program, due to their associated out-of-pocket expenses. We request that CMS consider removing this barrier to adoption by reclassifying CCM services as “preventive”; no longer subjecting Medicare patients to cost shares and deductible amounts. This new preventive classification would ensure all qualifying Medicare beneficiaries would have the equal opportunity to benefit from the CCM program without financial burden, like those patients dually enrolled in Medicare and Medicaid. Patient participation would immediately increase, leading to improved health outcomes and reduced cost of care for a larger segment of our most vulnerable patient population.
  • 2) We suggest that CMS expand the associated CCM Evaluation & Management (E/M) codes to include additional non-complex time spent each calendar month, beyond the currently covered and reimbursed 20 minutes of non-face-to-face services performed by clinical staff. It is the consensus of our clinician clients that the time spent providing CCM services to noncomplex patients often exceeds the 20 minute threshold. We request CMS to consider expanding non-complex CCM coverage to include add-on Evaluation & Management codes for additional non-face-to-face time increments (similar to the 99487 for complex services). The creation of these reimbursable codes would offset the costs to clinicians for the resources and services required to prevent costly exacerbations and avoidable readmissions for Medicare beneficiaries.
  • 3) We request further clarification regarding specific guidelines for CPT code G0506. Per the Department of Health and Human Services and Center for Medicare and Medicaid Services December, 2016 publication of Chronic Care Management Service Changes for 2017, 1G0506 is an Add-On code that, “can be billed in addition to the initiating visit service code when the billing practitioner personally performs extensive assessment and CCM care planning beyond the usual effort for the initiating visit code”.

We seek to clearly understand whether or not any qualified health professional (QHP) may perform and bill the associated services covered under the CPT G0506 using Medicare incident-to guidelines. CMS’ specific language choices of “personally performing” and “billing practitioner”, raise the question if the G0506 must be performed and billed under the directly under the billing practitioner’s NPI number, or if both may be billed and paid under CMS direct or indirect supervision, incident-to guidelines (like QHPs can perform and bill for other E&M services such as AWVs and non-face-to-face CCM services).

  • 4) Based on CMS’ published guidelines for CCM E/M codes 99490, 99487 and 99489, “any clinical staff may perform these services under the direction of the billing practitioner on an ‘incident to’ basis (as an integral part of services provided by the billing practitioner), subject to applicable State law, licensure and scope of the practice. The clinical staff are either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM”. 2

Community pharmacies and pharmacists are beginning to play a vital role, working under collaborative agreements established with primary care physicians and other billing clinicians, to provide CCM services. In this scenario and under CMS’ incident-to-guidelines not requiring direct supervision, both pharmacists and pharmacy technicians with a Pharmacy Technician Certification (CPhT) credential, may work together to perform these collaborative CCM services.We would like to request specific clarification as to whether or not the non-face-to-face services performed by the pharmacy technician (ie: collating patient data, reviewing/clarifying medication lists, etc.) may be counted towards the aggregated billable CCM time under codes 99490, 99487 and 99489, or if only time spent by the licensed pharmacist is billable and reimbursable by CMS.