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New Primary Care Codes for Payment

Summary

The method by which Current Procedural Terminology (CPT) codes are developed so that physicians can get paid for the services and procedures they provide is a very complicated process, one that deserves some explaining. Furthermore, ACP is actively engaged in this process and advocates for the best interests of its members, which includes improved payment for primary care and subspecialists under Medicare.

CPT codes are used to report medical services and procedures performed by physicians and other healthcare professionals. The CPT Editorial Panel meets throughout the year to review new and existing CPT codes for approval or updating. Values are assigned to new CPT codes and re-evaluated for existing codes by the Relative Value Update Committee (RUC), an advisory body that makes recommendations about the value of physician services to the Centers for Medicare and Medicaid Services (CMS). Payments to physicians are then made on a per-visit or per-procedure basis as defined by the CPT codes. Most private payers adopt the same values for services as CMS but may apply different conversion factors.

The RUC valuation process begins when RUC staff receives a summary of the CPT Editorial Panel’s new or revised codes as well as any potentially misvalued services identified by CMS. RUC staff will then prepare a “Level of Interest” form summarizing the CPT panel’s coding actions and specific CMS requests. Members of the RUC Advisory Committee and specialty society staff review the summary and indicate their societies’ level of interest in developing a relative value recommendation for any of the codes listed. The societies have several options:

  1. They can survey their members to obtain data on the amount of work involved in a service and develop recommendations based on the survey results;
  2. They can comment in writing on recommendations developed by other societies;
  3. In the case of revised codes, they may decide that the coding change does not require action because it does not significantly alter the nature of the service; or
  4. They may take no action because the codes are not used by physicians in their specialty.

ACP members may be selected to participate in the AMA/RUC survey for specific CPT codes for development of valuation recommendations. The College has two physician advisors who assist in developing and updating codes for internists and represent ACP at the CPT Editorial Panel meetings. Additionally, ACP has a delegate and back-up delegate who serve on the RUC and represent the interests of primary care physicians in the discussions of valuation for services. 

Below is a list of codes, that physicians can and are encouraged to use, highlighting the work ACP has done over the past few years to improve payment of primary care services:

Chronic Care Management and Complex Chronic Care Management

  • 99490: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month;
  • 99487: Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month;
  • 99489: Complex chronic care management services, each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

Care Planning

  • G0506: Comprehensive assessment of and care planning by the physician or other qualified healthcare professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service.

Psychiatric Collaborative Care Model

  • 99492: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional;
  • 99493: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional;
  • 99494: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional.

Behavioral Health Management

  • 99484: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month.

Advance Care Planning

  • 99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate;
  • 99498: Advance care planning; each additional 30 minutes.

Resources

For questions, please contact Brian Outland at boutland@acponline.org.