GAO Finds Medicare Billing Codes for Care Coordination, Planning

August 27, 2019 - Care coordination and planning are becoming increasingly important to caring for the millions of Medicare beneficiaries suffering from two or more serious health conditions, such as diabetes and heart disease. But many providers believe that current Medicare billing codes do not reflect the resources needed to provide such care.

To investigate the complaints, the Government Accountability Office (GAO) recently analyzed the Medicare Physician Fee Schedule to identify billing codes that reflect longitudinal comprehensive care planning (LCCP).

The federal watchdog found at least 58 existing Medicare billing codes that providers may use to bill for LCCP-type services, which include a conversation with the beneficiary diagnosed with a serious illness, shared decision-making through an interdisciplinary team that includes a physician, registered nurse, and social worker, development of a longitudinal care plan that is shared with the beneficiary, and a care plan that addresses beneficiary goals, values, and preferences, as well as the availability of other resources or social supports.

GAO determined that the 58 billing codes generally contain components that are equivalent to the key aspects of LCCP services. For example, all 58 of the billing codes included a provision for the development of a care plan that addresses beneficiary goals, values, and preferences, and a provision for coordination with other providers, which aligns with the LCCP service related to interdisciplinary care, the watchdog reported.

Of the 58 identified billing codes, 45 are broadly-defined codes, including 39 evaluation and management (E/M) codes that have existed for decades, GAO pointed out.

READ MORE: Exploring the Fundamentals of Medical Billing and Coding

The remaining 13 billing codes for LCCP-type services were considered narrowly-defined because they accounted for the time spent coordinating care for patients with complex treatment needs. Narrowly-defined codes included services for transitional care management, chronic care management, advance care planning, and behavioral health integration.

Providers, including 13 stakeholders interviewed by GAO, state that the existing billing codes either do not require or do not sufficiently reimburse them for the time spent on interdisciplinary care. They supported the creation of a separate code to reimburse for that type of care.

However, GAO’s analysis of the 58 billing codes showed the majority of the codes included a provision for consultation and coordination among providers that is the same as input from an interdisciplinary team. Furthermore, total reimbursement for the combination of billing codes related to this type of care was about $203 as of 2019.

GAO also addressed provider concerns about insufficient physician time for care planning.

Several stakeholders stated that complex E/M codes do not allow providers to bill for the time it takes to deliver both care management of a complex patient and care planning for that patient, which they felt were two separate and distinct activities.

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CMS recently created new prolonged E/M codes, which allow for an additional 60 minutes of time on top of the 40 already allotted for care planning and coordination activities. But stakeholders also expressed concerns about the new E/M codes, stating that the prolonged time does not address the problem of insufficient time because the code can only be billed with a companion code and the time needed to bill the two codes together is too high.

GAO reviewed CMS guidance on billing prolonged E/M codes and found that providers do not need to meet the full 60 minutes of additional time in order to bill the code. Providers use the billing code as long as the total time spent on the visit exceeds the typical time of an E/M visit plus 30 minutes.

The watchdog also addressed the concerns of a minority of stakeholders, including documentation requirements.

Three of the 19 stakeholders representing providers stated that burdensome documentation requirements for more complex E/M codes prevented them from billing the codes. But GAO’s analysis of  Medicare Part B claims from 2017 showed that certain specialties, including some that expressed this concern, billed the more complex codes at a significantly higher rate than the average across all specialties.

“This may indicate that these documentation requirements do not necessarily preclude providers from billing these codes,” GAO stated.

READ MORE: The Difference Between Medicare and Medicaid Reimbursement

The analysis suggests that a new Medicare billing code may not be necessary to implement the care planning and coordination services needed to care for more complex patients. But stakeholders agreed that if CMS did develop a new LCCP code, the definition of interdisciplinary team should be flexible and not require a social worker, GAO reported.

“13 stakeholders stated that a typical practice did not include a social worker, but rather included a nurse who might perform the functions of a social worker,” the watchdog wrote. “They stated that smaller office-based medical practices could not afford to hire a social worker.”