Is it a new era in Medicare? Are we rocketing into a new Medicare that has extensive resources for care navigation and care coordination? This article unravels some new 2024 policies, and shows a surprising connection between "new codes" and White House cancer policy.
For a quick overview, see an AI summary of this blog here.
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A Bit of History
Traditionally, Medicare Part B paid for direct physician services (and services incident-to a physician, like the nurse giving the flu shot). Getting anything other than a direct and face-to-face physician service was pretty difficult.
- For example, take-home, home-use allergens from an immunologist had to receive their own statutory benefit category (found at SSA 1861(s)(2)(G)) since they were not a face-to-face service at the time of use, at home.
Then some bona fide non-face-to-face services were introduced, like physician monthly care management plans for home health or hospice (G0181, '82). These codes go back decades and pay about $100/month (2022, G0181, 400,000 uses for $42M; G0182, 34,000 uses for $3.5M). The key feature of the home health and hospice management code pair is, that they are for not-face-to-face services, which at the time was quite uncommon.
Care Management Services
There are now a lot of care management services, and CMS provides a 15 page PDF guide vintage 2021, which will have to be a few pages longer when updated for 2024. Be aware that I'm only cherry-picking a few of the long list of care management codes.
In this blog, enjoy a snapshot of part of what's recent or even brand new in the last several weeks. I find this area of care management and navigation services to be extremely interesting, because many genomics labs (see my recent blog about YouScript and Tempus AI here) are featuring their integration into care pathways and their role at decisional timepoints in care management. Navigating cancer care would certainly include navigating the access to, and flow of funds for, genomic tests. Is it a "you snooze, you lose" proposition for genomics labs?
[Separately, re AI and care management, see the extremely proactive recent HHS rulemaking on any kind of AI (any algorithm with data), whenever incorporated into EHR services - here).
AMA, White House on Navigation
See a special AMA update on new care management codes here and here.
Remarkably, see a White House announcement about the new care navigation codes, their relevance for oncology patient navigators, and their role in the larger Cancer Moonshot project. From the WH Office of Science and Technology Policy, OSTP, they also cite to an auxiliary document on standards for high quality care navigators/navigation here (in, The Journal of Cancer Navigation, update, here). Bills to require patient navigators in Medicaid have been floated (here). The White House document was written by Anabella Aspiras, who worked on Cancer Moonshot under Obama (2016) and rejoined in January 2023. (In between she was with Mendel.AI).
Code Set #1
"Principal Care Management"
See codes 99424, 99426, which are physician or qualified health care professional [PA, NP] care management services, first hour, and add-on hour. (2022, 99424, 75,000 uses, $6.5M, $87; 99425, 23,000 uses, $1.M, $64.) There are also a pair of codes for "clinical staff" directed by a physician, 99426, 99247, paying about 2/3 as much and used in roughly the same volumes.
- See CMS 2021 15-page PDF guide.
- See Medical Economics here. See Thoroughcare.net here.
- See code text at bottom.
The code is an add-on code to office visits that adds $17 (prorated for more expensive areas). This was generally opposed by procedural specialties who either don't bill E&M (e.g. radiology, pathology) or who have bundled postsurgical visits (e.g. surgeons) rather than standalone E&M codes. CMS estimated it could be added to as many as a third of primary care visits.
See 88 FR 778937ff (November 16, 2023); regarding outsourcing, "PIN services provided by auxiliary personnel who are external to, and under contract with, the practitioner or their practice..." see p. 78947-8. I am not an attorney and I refer companies to Medicare policy attorney experts for interpretation of the rule and formation of such outsourcing contracts (e.g. creating a close financial relationship but without kickback concerns).
In another care area, the creation of AMA's "remote physiological monitoring" or the RPM and related codes, a whole sub-industry of service providers appeared quickly who could provide the home monitoring equipment to the patient as subcontractors to the physician receiving the CMS RPM code fee. [Find just one of them here.] I suspect both RPM and PIN fields will development their own case studies, compliance best practices, and legal experts, and perhaps OIG advisory opinions.
- Boom, Here's New Policy. Major new areas of policy - G2211 and the G0023/G0140 series - are being introduced in November, and will be active in January, probably before MACs have time to write any guidance articles or even LCDs on the topic.
- CMS transmittal November 22, 2023, to MACs, CR13452, has just a few vague sentences in comparison to the lengthy pages of CMS policy in the November 16 Fed Reg.
- Nerdy CR. Though there's already one nerdy CMS followup, CR13272, re use of -25 modifier.
- AAFP tries to fill the gap with "coding tips" for G2211.
- Who Says What "Trained" Means? For example, G0023 refers to staff who are "credentialed and trained." What constitutes credentialing? Bob's Credentialing? What constitutes training? 15 minutes? 15 hours? 15 months? CMS isn't saying, nor are MACs. So nobody knows the answers for sure. Will some of the answers and enforcement vary MAC to MAC - undercutting the even distribution (the social equity) of the new federal benefit?
- Doctor Hires Incident-To Staff Out of State? If a doctor hires [contracts] what Medicare legally calls healthcare incident-to staff, out of state, are their any implications? The benefit doesn't seem like "medical practice," but CMS classifies it as a service "reasonable and necessary to diagnose or treat illlness," which does.
- That said, the older codes 99424,'26, have been around 2 years and seem to have no guidance yet on the Medicare Coverage Database.
- Outsourcing Compliance TBD. How the new codes G0023 etc for PIN will interface with an outsourcing industry while remaing "under general supervision and incident to the physician" remains to be seen.
- It seems like physicians who get paid for the G0023 service for PIN, who use outsourced navigators, would be vulnerable to the navigators' medical records quality if the physician gets audited.
- It seems like navigators could use a lot of time in 60 and 30 minute periods. It takes time to be acquainted with the highly complex patient before starting to coordinate, many of the tasks in the code text seem time-consuming, and don't care coordinators spend a lot of time on hold?
- "Creation of a Benefit by Proxy." If service providers with no statutory benefit- e.g. "care navigators" or "peer care navigators" can be paid via an incident to and removte general supervision benefit, I'm at a loss to know why genetic counselors might not be paid this way.
- (Historically, I think genetic counselors have been considered as taking on parts of the healthcare that would otherwise be a doctor's E&M benefit, but E&M can only be billed by MD/DO/PA/NP).
- "It's a Code." It's interesting that what look like a new form of healthcare benefit requires no action in statue, or even action in regulation, or even subregulatory policy printed by MACs. Instead, all the annual rule acomplishes for G0023/G0140 is the creation of massively long HCPCS G-codes that themselves look and read almost like C.F.R. regulations.
- It's unlikely doctors or coders or MACs would read the dozens of pages of Fed Reg rulemaking.
- The $100-plus payments ofor PIN have some similarities to the $160/mo payments in the CCMI Oncology Care Model ver1 (here), which wasn't all that successful.
- one complex chronic condition expected to last at least 3 months,
- and that places the patient at significant risk of hospitalization, acute exacerbation/ decompensation, functional decline, or death,
- the condition requires development, monitoring, or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen,
- and/or the management of the condition is unusually complex due to comorbidities, ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional [PA NP],
- per calendar month
- 99425: Additional half-hours
- Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services
- and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition
- or a complex condition.
- {Add on to E&M]
- including a patient navigator;
- 60 minutes per calendar month,
- in the following activities:
- person-centered assessment, performed to better understand the individual context of the serious, high-risk condition.
- ++ conducting a person-centered assessment to understand the patient's life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors and including unmet sdoh needs (that are not separately billed).
- ++ facilitating patient-driven goal setting and establishing an action plan.
- ++ providing tailored support as needed to accomplish the practitioner's treatment plan. identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services. practitioner, home, and community-based care coordination.
- ++ coordinating receipt of needed services from healthcare practitioners, providers, and facilities; home- and community-based service providers; and caregiver (if applicable).
- ++ communication with practitioners, home-, and community-based service providers, hospitals, and skilled nursing facilities (or other health care facilities) regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors.
- ++ coordination of care transitions between and among health care practitioners and settings, including transitions involving referral to other clinicians; follow-up after an emergency department visit; or follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
- ++ facilitating access to community-based social services (e.g., housing, utilities, transportation, food assistance) as needed to address sdoh need(s). [social determinant of health]
- Health education- helping the patient contextualize health education provided by the patient's treatment team with the patient's individual needs, goals, preferences, and sdoh need(s), and educating the patient (and caregiver if applicable) on how to best participate in medical decision-making. building patient self-advocacy skills, so that the patient can interact with members of the health care team and related community-based services (as needed), in ways that are more likely to promote personalized and effective treatment of their condition. health care access / health system navigation.
- ++ helping the patient access healthcare, including identifying appropriate practitioners or providers for clinical care, and helping secure appointments with them.
- ++ providing the patient with information/resources to consider participation in clinical trials or clinical research as applicable. facilitating behavioral change as necessary for meeting diagnosis and treatment goals, including promoting patient motivation to participate in care and reach person-centered diagnosis or treatment goals.
- facilitating and providing social and emotional support to help the patient cope with the condition, sdoh need(s), and adjust daily routines to better meet diagnosis and treatment goals.
- leverage knowledge of the serious, high-risk condition and/or lived experience when applicable to provide support, mentorship, or inspiration to meet treatment goals.
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