CMS looks to fortify primary care with proposed new codes for advanced care management

With newly proposed regulations, CMS aims to establish coding and payment for services that promote longitudinal relationships between clinicians and patients in primary care.

The provisions, part of Medicare’s 2025 proposed rule for physician payments, incorporate new HCPCS G-codes for advanced primary care management (APCM).

Three bundles of APCM services would be billable as codes GPCM1, GPCM2 and GPCM3, according to the proposal. The bundles and corresponding work relative value unit (RVU) would be for:

• Patients with one or fewer chronic conditions (RVU of 0.17)
• Patients with two or more chronic conditions (RVU of 0.77)
• Patients with two or more chronic conditions who are dually eligible for Medicare and Medicaid and qualify to have cost-sharing waived (RVU of 1.67)

The first level is intended to be similar to two billing units of the non-complex code for chronic care management services (CPT code 99490). In turn, the second level would be equivalent to five units of that code and four units of add-on codes.

The payment rate for the third level would be based on a multiple of billing units in the second level, reflecting patients for whom social determinants of health are a greater factor.

“The context here is … the actions [CMS has] taken to really try to simplify coding, actually bring more dollars into the codes [and] to try to simplify the administrative aspects of this and make this available to physicians and nonphysicians alike who are providing primary care,” Amol Navathe, MD, PhD, professor of health policy, medicine and healthcare management at the University of Pennsylvania, said during a webinar hosted by the Primary Care Collaborative (PCC).

Navathe did say he wonders whether the rates for services provided to less-complex patients would be adequate to incentivize proactive care among practices with large shares of such patients.

Scope of services and other requirements

As summarized in Table 21 of the proposed rule, use of the codes would require providers to implement various service elements and capabilities. Among others:

• 24/7 access to care and care continuity
• Comprehensive care management, including a care management plan
• Management of care transitions
• Enhanced communication opportunities (e.g., asynchronous communication)
• Patient population-level management (i.e., identifying and filling gaps in care)

Participation in quality measurement would be required by linking APCM payment to the Value in Primary Care value pathway of the Merit-based Incentive Payment System, CMS proposed. Categories in that pathway include quality, total cost of care and meaningful use of certified EHR technology.

The reporting requirement is already met for participants in the Medicare Shared Savings Program or advanced primary care models such as ACO REACH and Making Care Primary. CMS hopes the new codes will present a path for more physicians to join accountable care organizations (ACOs), Doug Jacobs, chief transformation officer with CMS’s Center for Medicare, said during the PCC webinar.

One aspect of quality measurement is gauging whether providers are following evidence-based practices, Navathe noted, but that prism may be too narrow.

“That’s different than [asking], ‘Are we enabling practice transformation? How do we do that without really stimulating a ton of administrative burden?’ I think that’s the real critical, challenging question,” Navathe said.

Jacobs noted the codes also promote team-based care, allowing services to be billable when provided by auxiliary clinical staff who are under the general supervision of the billing practitioner. He also explained that duplicative billing in relation to existing codes for care management and communication-based technology would be prohibited.

A simpler mechanism

Prior attempts to implement care management codes have been hampered by administrative burdens. The bundled structure of the services covered by the new coding is intended to make life easier for clinicians and coders, including by allowing for billing to take place on a per-member-per-month basis.

“Part of the main barrier to reporting [care management codes] is the need to document every minute that [such care] is being delivered and also needing to hit certain thresholds to be able to bill the services,” Jacobs said. “These codes get rid of some of those administrative barriers. There is no time-based billing requirement. There’s no minimum threshold of minutes that you need to reach every month in order to be able to bill the codes.”

The approach is likely to come as a relief for smaller provider organizations in particular.

“One of the things we see with our primary care physicians is that there just are so many different ways to code for care management and transitions and support, [and] for coordination, that it gets very confusing,” Amy Milewski McKenzie, MD, vice president for clinical partnerships and associate chief medical officer at Blue Cross Blue Shield of Michigan, said during the webinar. “You need a lot of resources within the practice.”

Next steps for primary care

The proposed rule includes a request for information on ways to build on the APCM bundle via a hybrid payment model that incorporates principles of team-based accountable care, potentially encompassing evaluation and management (E/M) services.

The proposed APCM codes are “an important first step as part of a multiyear effort,” Meena Seshamani, MD, PhD, director of CMS’s Center for Medicare, said during the webinar.

Part of the intent is to promote alignment in such models with Medicaid and commercial insurers. The newly proposed bundles can help in that respect because CMS codes are viable across payers, Jacobs noted.

“If you don’t see multiple payers moving in the direction of creating payment [for specific services], it just becomes too complicated for the [physician] offices, and they’re not going to do it,” McKenzie said.

One issue for policymakers to consider is the continued requirement for cost-sharing among many Part B beneficiaries under the new codes. The out-of-pocket costs might dissuade some patients from taking advantage of the enhanced services.

Stakeholders on the webinar said they hope Congress will follow through on preliminary plans to alleviate the cost-sharing obligation specifically with respect to advanced primary care.