Chronic Care Management Program

Transitional Care Management, Chronic Care Management, Principal Care Management, Remote Patient Monitoring

Centers for Medicare & Medicaid Services (CMS) acknowledged that less than 10% of Medicare fee-for-service beneficiaries presently receive ambulatory care management services. Therefore several important changes to expand access to these services were made. CMS released 2020 Medicare Physician Fee Schedule Final Rule (Final Rule) November 1, 2019. The following is the summary of new Medicare reimbursement rules for Transitional Care Management , Chronic Care Management , Principal Care Management , and Remote Patient Monitoring:

TCM – Transitional Care Management

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Fee increase
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Now allows other care management to be concurrently billed with TCM

According to CMS, a recent analysis of Transitional Care Management claims data determined that Transitional Care Management services utilization is low (1.3 million claims for TCM in 2018 compared to approximately 9.5 million Medicare hospital discharges that year). However, for those who have received it, the same study demonstrated lower readmission rate and mortality and decrease in health care spending.

To increase Transitional Care Management utilization, CMS is now allowing a practitioner to bill for chronic care management and care plan oversight furnished during the same time period as Transitional Care Management.
Furthermore, CMS is increasing the work relative value units (RVUs) for the two Transitional Care Management CPT codes.

CCM – Chronic Care Management

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New code for each additional 20 minutes of care management beyond 20 minutes per month
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CCM removes requirement for "substantial care plan revision"

CMS acknowledged that Chronic Care Management, while it has demonstrated cost savings, and increase in both patient and provider satisfaction (part of the quadruple aim) is being underutilized. To address this, CMS is creating an add-on code for non-complex Chronic Care Management.

CMS is making one minor revision to the list of items typically included in the required comprehensive care plan , replacing "community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identify the individuals responsible for each intervention" with this language: "interaction and coordination with outside resources and practitioners and providers."

Complex Chronic Care Management codes no longer require "substantial care plan revision. This requirement limited care for many folks requiring 60+ minutes of care coordination where there may not be a "substantial care plan revision" as defined by CMS. To prevent overuse, Medicare is keeping the "moderate or complex medical decision making" requirement in place.

PCM – Principal Care Management

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Care Plan: PCM requires a "disease-specific" care plan vs. Chronic Care Management's comprehensive care plan
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Documentation: PCM requires that communication/care coordination "between all practitioners furnishing care to the beneficiary...be documented by the practitioner billing for PCM in the patient’s medical record."

Medicare finalized 2 codes relating to Principal Care Management to cover patients with a single serious chronic condition. This enables care management for patients who don't qualify for Chronic Care Management's 2-condition requirement.

RPM – Remote Patient Monitoring

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RPM communications could be performed under general supervision of the billing practitioner
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New code for each additional 20 minutes of clinical staff communication beyond 20 minutes per month

Similar to non-complex Chronic Care Management, Remote Patient Monitoring requires 20 minutes of clinical staff time per calendar month reviewing and taking action based on data reported through Remote Patient Monitoring, including interactive communication with the patient or caregiver. CMS previously has required the billing practitioner to provide direct supervision (i.e., in-person) for clinical staff furnishing Remote Patient Monitoring services. Effective January 1, CMS will permit these services to be performed under general supervision.