CMS Proposes to Expand CCM Codes… Again!

Good news for the Chronic Care Management industry, and the millions of patients benefiting from this added layer of care. CMS proposes implementing a set of Medicare-developed HCPCS G codes that will enable better coordinated care and care management of patients with one or more chronic conditions. (Yes, we said “one”).

After receiving feedback from stakeholders, CMS proposes replacing a number of the CCM codes with Medicare-specific codes. This will allow clinicians to bill incremental time and resources required in certain cases and to better distinguish complexity of illness.

Non-Complex Chronic Care Management

Let’s start with “Non-Complex” CCM. CMS is proposing two new G codes—GCCC1 and GCCC2—to be used for PFS payment. These G Codes would replace CPT code 99490. Once the CPT Editorial Panel has convened, there is a high likelihood that the G Codes will be replaced with CPT Codes.

Non-Complex Chronic Care Management G Code GCCC1

GCCC1 is essentially the replacement for what most people think of with Chronic Care Management – the initial 20 minutes of clinical staff time directed by a physician or other qualified health care profession, per calendar month. The requirements are a crosswalk from CPT 99490. CMS proposes a work RVU of 0.61, which is in line with CPT 99490.

Non-Complex Chronic Care Management G Code GCCC2

Here is where things get exciting. CareHarmony applauds CMS’s proposed addition of G Code GCCC2, which is designed to account for each additional 20 minutes of clinical staff time directed by a physician or other qualified health care profession, per calendar month. GCCC2 is meant to be used in conjunction with GCCC1. So, for example, if a Chronic Care Management Care Coordinator spent 52 minutes caring for a patient, claims could now be submitted for GCCC1 & GCCC2, which more accurately reflects the time/resources allocated to care for the patient. CMS proposes a work RVU of 0.54.

CMS notes, an eligible provider may not report GCCC1, GCCC2 in the same calendar month as GCCC3, GCCC4, 99491. See below for greater details on GCCC3 and GCCC4.

Complex Chronic Care Management G Code GCCC3

GCCC3 is essentially a replacement, or crosswalk, for CPT 99487.   GCCC3’s requirements are almost identical to CPT 99487, with the similar but modified language for establishing the “Complex” criteria: moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. Complex CCM codes GCCC3 & GCCC4 no longer require “substantial care plan revision”. Under the current codes (CPT 99487 & 99489) this requirement potentially limited care for many patients requiring 60+ minutes of care coordination where they may not be a ‘substantial care plan revision’ as defined by CMS. CMS proposes a work RVU of 1.00.

Complex Chronic Care Management G Code GCCC4

GCCC4 is the replacement/crosswalk for CPT 99489—each additional 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. Just like with CPT 99487/99489, you would report GCCC4 in conjunction with GCCC3.   CMS proposes a work RVU of 0.5.

Of the new codes, clearly G Code GCCC2 is the only significant change. The other three codes are simply replacements for existing codes.

Care Plan Clarification:

In order to clarify its policy, CMS proposes the following new language for a comprehensive care plan:

The comprehensive care plan for all health issues typically includes, but it not limited to, the following elements:

• Problem list;
• expected outcome and prognosis;
• measurable treatment goals;
• cognitive and functional assessment;
• symptom management;
• planned interventions;
• medical management;
• environmental evaluation;
• caregiver assessment;
• interaction and coordination with outside resources and practitioners and providers;
• requirements for periodic review; and when applicable, revision of the care plan.

For more information, we have provided a copy of the Proposed Rule Changes.

In addition to these changes, CMS has proposed a new Principal Care Management (PCM) service for patients with one complex chronic condition. Check out our blog post on PCM for the details.