AMA to Medicare: Begin Paying for Care Coordination in 2012

October 12, 2011 — An influential committee of the American Medical Association (AMA) has issued a challenge to Medicare: If you are serious about the patient-centered medical home, show us the money in 2012.

That group, the AMA/Specialty Society Relative Value Scale Update Committee (RUC), is asking the Centers for Medicare and Medicaid Services (CMS) to start paying separately for certain care coordination services for the chronically ill:

• telephone consults with patients;


• education and training for patient self-management performed by nonphysicians;


• medical team conferences, regardless of whether the patient is present; and


• anticoagulation management.

Right now, such services are generally considered rolled into, and reimbursed under, evaluation and management (E&M) services, epitomized by office visits with established patients. In addition, such services all involve care that does not hinge on a face-to-face encounter between physicians and patients. Organized medicine has long complained that although Medicare pays for the work that occurs in the exam room, it does not adequately compensate physicians for what they do once the patient walks out the door.

The new healthcare reform law aims to solve this payment problem through the medical home, which consists of clinician teams, usually lead by physicians, that will receive a monthly fee for care coordination on top of fee-for-service reimbursement. CMS is testing the medical home concept through pilot projects.

RUC, however, wants quicker, broader action. In a letter to CMS last week, RUC Chair Barbara Levy, MD, asked the agency to begin reimbursing care coordination services for the chronically ill next year on a short-term, piecemeal basis until a more comprehensive approach, such as the medical home, is in place. By doing so, Dr. Levy says, CMS would demonstrate that it "is prepared to incentivize care coordination and foster delivery reform."

While boosting Medicare spending up front, separately reimbursed care coordination services will pay for themselves by eliminating unnecessary office visits, trips to the emergency department, hospitalizations, and prescriptions, she added.

CMS can ignore RUC's recommendations. However, the agency is in the habit of listening to them. It relies heavily on the AMA committee for input when, every 5 years, it updates the relative value units that make up the resource-based relative value scale, which is used by CMS to price physician services.

Codes Already Exist, but Go Unreimbursed

RUC's proposal to CMS is couched in the words and numbers of Current Procedural Terminology (CPT) codes, which are developed and maintained by the AMA for reporting services and procedures performed by physicians. CMS has officially adopted this code set as the means to bill Medicare and Medicaid for physician services.

However, just because the AMA creates a CPT code for a particular service does not guarantee that Medicare and Medicaid will necessarily reimburse it. Case in point are CPT codes 99363 and 99364 for anticoagulation management. The AMA's CPT editorial panel created them in 2007, using 99363 for the first 90 days of such therapy and 99364 for each subsequent 90-day period. In her letter to CMS, Dr. Levy noted that the agency had calculated the reimbursement for the 2 codes ($41 per month for 99363, and $14 per month for 99364), but never authorized paying for them, reasoning that managing someone's warfarin regimen was bundled into E&M reimbursement. RUC is asking CMS to begin paying for these codes on their own.

Other care coordination services listed in the RUC letter also come with codes already on the books:

• Education and training for patient self-management, CPT codes 98960 to 98962: These apply to sessions conducted by nonphysicians such as a registered nurse on a physician's staff.


• Telephone services, CPT codes 99441 to 99443 and 98966 to 98968: These codes are designed for telephone conversations initiated by an established patient that do not originate from a related E&M service within the previous 7 days or lead to an E&M service or procedure within the next 24 hours, or at the soonest available appointment. The first set of codes is for telephone conversations between patients and physicians. When another kind of clinician takes the call, the second set of codes applies.


• Medical team conferences, CPT codes 99366 to 99368: The 99366 code pertains to nonphysicians who confer together with the patient or family members; 99368 is for such nonphysician conferences when patient and family are absent. The 99367 code describes team meetings that include a physician, but not a patient or family members.

Someday, "One Big Code" for Care Coordination

The RUC recommendation to pay for care coordination on a piecemeal basis until the medical home model is in place drew nods of approval from domains of organized medicine beyond the AMA.

"These are short-term fixes, but they recognize the value of work done outside the face-to-face visit, which has not been properly paid for," Lori Heim, MD, who chairs the primary care payment valuation task force of the American Academy of Family Physicians, said in an interview with Medscape Medical News. "[The RUC proposal] could be a real game-changer."

Likewise, Shawn Martin, director of government relations for the American Osteopathic Association, called the RUC recommendations an interim step toward a "comprehensive payment model."

"We're pretty pleased," Martin told Medscape Medical News. "Compensation for services outside the face-to-face visit is a core element of the medical home. Ultimately, you will have one big code for an undefined set of services."