By Phillip E. Rodgers, MD FAAHPM
Co-chair, AAHPM Public Policy Committee and Quality-Payment Working Group
AAHPM Representative, American Medical Association/Specialty Society Relative Value Scale Update (RUC) Advisory Committee

On Nov. 15, the Center for Medicare and Medicaid Services (CMS) published the 2017 Medicare Physician Fee Schedule (PFS) Final Rule. (Access a CMS Fact Sheet.)  Each year, the PFS designates how  – and how much – physicians and eligible billing practitioners get paid through the Medicare Part B program, which continues to cover roughly 70% of all Medicare beneficiaries (and many, if not most, of the patients seen by palliative care teams).

In recent years, AAHPM has been collaborating with specialty society partners and meeting with CMS officials to advance new codes that value non face-to-face work and more appropriately recognize the work of coordinating care for complex patients. So we were very pleased to see that earlier this year CMS proposed to include some of these codes in the PFS and make other significant changes that could positively impact palliative care teams. (Read AAHPM’s comments on the Medicare PFS proposed rule.) Nearly all of these proposals were just finalized and will become effective Jan. 1.  While it will take a few weeks to fully digest all the details in the final rule, here are five key changes for 2017 that you should know about:

1) New Payment for Advance Care Planning Services Provided via Telehealth. For those of you providing CMS-approved telehealth services (and you know who you are), you can now use the advance care planning (ACP) codes to bill for ACP services. While currently limited to patients in rural or health professional shortage areas, telehealth may expand significantly in the future.

2) 30% Increase in Payment for ‘Prolonged Face-to-Face Services’ in the Outpatient and Home Settings. Many HPM clinicians use prolonged face-to-face services codes to describe services like extended family meetings, time-intensive symptom management, and complex medical decision making. In 2017, payment for prolonged F2F services in the outpatient or home setting only, will increase by 30 percent.

3) New Payment for ‘Prolonged Non Face-to-Face’ Services. Starting in January 2017, Medicare will start making payment for significant ‘non face-to-face’ time spent in activities like reviewing patient records or interacting with referring clinicians, families, and interdisciplinary team members in preparing for (or following up on) an E/M visit in the hospital, clinic or home setting.  This is a potential game changer. As long as code requirements are met (e.g. at least 30 minutes spent on a single day, which may or may not be the same day as the related E/M code), billing practitioners can now get paid for this valuable and previously unreimbursed time.

4) New Payment for ‘Complex’ Chronic Care Management. Starting in 2017, Medicare will now start making payment for ‘complex’ chronic care management codes (CCCM):  99487 (first 60 minutes) and 99489 (each add’l 30 minutes). These codes reimburse time spent by non-billing clinicians (RNs, LPNs, medical assistants, social workers, spiritual care providers and others) in care outside face-to-face visits. Compared to the existing chronic care management code (99490, billable just once a month), these codes describe more involved services for more complex patients.  They also pay at a significantly higher rate and can be billed as many times as necessary to reflect the time spent during a given month.

There are important details about these services (beneficiary consent, cost-sharing, etc.) which need to be considered but, for palliative care teams that are providing care coordination services to their patients, this could be a significant source of new revenue to help support the interdisciplinary team.

5) New Codes and Payment for Behavioral Health Integration and Cognitive Impairment Assessment and Management. These are two big, new additions to the PFS that describe and value the work of psychiatric collaborative care (using psychiatrists and behavioral care managers in primary care practices) and assessment of cognitive impairment and dementia (which, notably, has a requirement to address advance care planning and palliative care needs of patients with cognitive impairment). These code sets have many moving parts and are worth getting to know well, particularly if you or others in your organization provide these specific services.

More importantly, these additions signal Medicare’s willingness to work closely with the provider community to break new ground in describing and paying for patient-specific, non-procedural services and could lead the way to describing other services (like, for example, palliative care assessment and management).

Well, if you’ve made it this far, bravo!  You may also be thinking:  Why should I care about this stuff, or the Medicare PFS at all?  It seems very complicated, confusing, and difficult to keep track of in my busy clinical life.  And isn’t fee-for-service dying anyway? Valid points, but I’ll leave you with two reasons to care.

First, fee-for service payments from Medicare (and the vast majority of commercial payers who follow Medicare’s lead) remain big sources of professional fee revenue for palliative care providers.

Second, while we are clearly moving to value-based reimbursement, the architecture of the PFS will remain very pertinent. The majority of the changes coming with implementation of Medicare’s new Quality Payment Program—through the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways—are built on a fee-for-service chassis. This is intentional, and not only allows a smoother transition to new payment models but also retains what is still our best (if very imperfect) system to describe and value the work of clinicians caring for patients and families.

The 2017 Medicare PFS Final Rule makes measureable progress in this regard, and so deserves our attention. Review it with your favorite billing colleague or consultant, and see how you can take advantage of its new opportunities. In the meantime, AAHPM will both continue to work with stakeholder specialty societies to advance reimbursement for high-value, cognitive care services not currently described or paid for under the PFS as well as engage HPM thought leaders to support an Academy strategy aimed at advancing palliative care in emerging payment models.