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A new CMS rule will allow payments for physicians for the time they and their clinical teams spend managing Medicare patients’ chronic conditions beyond face-to-face office visits.
Under current Medicare rules, physicians are not reimbursed for tasks such as answering questions from patients and caregivers; answering questions from referral specialists and pharmacists; reviewing lab and imaging tests; assessing a patient’s functional status; coordinating appointments; or developing care plans. Physicians are not compensated for these tasks because Medicare considers these services part of the patient’s prior or upcoming face-to-face visit. All of this will soon change, although few physicians realize it yet.
The new G-code
Enter “G-code” for Chronic Care Management Services. The G stands for Government, as in the Centers for Medicare & Medicaid Services, which devised this code as a way to incentivize doctors to do a better job coordinating patients’ care.
As the agency spelled out in its late November Physician Fee Schedule rule, physicians will be able to bill separately for these types of non-face-to-face services starting Jan. 1, 2015. This is in addition to payment for evaluation and management (E/M) codes covering the face-to-face encounter. The G-code is valued at only 20 minutes of non-face-to-face activity per Medicare beneficiary every month, or roughly $30.
CMS began paying physicians for non-face-to-face care in January 2013, but only for care coordination for patients transitioning from a hospital to a post-discharge setting or as spelled out in a few other limited pilot projects.
How G-codes can be used:
- The patients eligible for G-code services must have two or more chronic conditions expected to last at least 12 months or until the patient’s death and that place the patient at significant risk of death or functional decline.
- The physician can bill for the services only once a month, but must document a minimum of 20 minutes doing this non-face-to-face activity each month. Even if the physician’s team spends five hours a month on these services, the payment will only be for 20 minutes.
- The physician or another qualified eligible professional, such as an RN or a PA, can provide the service, but someone with clinical expertise has to be available 24/7, “regardless of the time of day or day of the week,” according to the rule.
- Because the service now becomes a billing claim, part of the cost will be paid with the patient’s coinsurance under Medicare Part B at about 20%. Because of that, patients will have to give the physician consent to receive services billed under G-codes, and of course CMS will require documentation. This might be a problem if patients say no.
- CMS put off two provisions contained in its proposed rule. It dropped the requirement that individuals responding to 24/7 calls have access to the full patient record through an electronic health record. It also dropped the requirement that the practice be certified as a medical home. CMS indicated it will revisit those issues in future rules.
Other types of improved quality might include following up with referral specialists to make sure the patient was seen and what type of care occurred. Practices might block out time at the end of each day to accomplish these tasks that otherwise slip through the cracks.