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Complex Chronic Care Management Reimbursement for 2015 Included in Proposed 2014 Physician Fee Schedule [Ober|Kaler]

Payment Matters

The proposed 2014 Medicare Physician Fee Schedule included reimbursement for case management to be made available in 2015 for physicians who treat patients with two or more complex conditions. The proposed rule would reimburse those physicians for non-face-to-face case management services, including developing a plan of care, communicating with other health care providers and medication management. CMS will accept comments on the proposed rule until 5:00 pm on September 5, 2013.

CMS proposed several requirements for the chronic care management payment and sought comments from stakeholders on others. The requirements ranged from billing prerequisites to minimum written protocols, including:

  1. Each Medicare beneficiary had an Annual Wellness Visit or Initial Preventive Physical Examination in the previous 12 months.
  2. The practice makes care available to the patient on a 7 day a week and 24 hour per day basis.
  3. The practice uses a certified Electronic Health Record.
  4. The practice must employ one or more advanced practice registered nurses or physician assistants to meet the needs of the patients who require complex chronic care management services.
  5. The practice must provide at least one hour of complex chronic case management services during a 90 day period to be eligible for reimbursement.

Ober|Kaler's Comments

CMS proposed that the complex chronic care management services reimbursement program would start in 2015. CMS included this proposal in the 2014 fee schedule to encourage stakeholders to provide comments and allow CMS time to develop meaningful standards for the program. It is clear from the proposal that CMS will expect providers to meet numerous prerequisites in information technology infrastructure, personnel and personnel training, and practice protocols to be eligible to be reimbursed under this program. Stakeholder groups should consider whether these prerequisites would discourage or enable meaningful care management services to these patients.

The proposed reimbursement also presents two interesting reimbursement problems. The first is whether physician care management services will be reimbursed in other situations such as transitional care management following hospital discharge, or hospice or home health care when a physician is reimbursed under the proposal. CMS proposed that if the complex chronic care management services are billed, CMS would prohibit billing separately for existing services such as transitional case management services, home health care supervision, and hospice care supervision. The second is what impact the proposed reimbursement might have on hospital admissions. Theoretically, complex chronic care management services should assist in providing more efficient care to a chronically ill population and could help prevent costly hospital admissions.

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