The care-management codes PCPs may be leaving on the table
Industry Buzz
The physicians who get the most from these codes treat them as the operating backbone of value-based care, not a side-billing play.
—Sirisha Bommireddipalli, CMPE, CHBC, CPC, CEO of MedConverge
It’s no exaggeration to say that primary care or internal medicine physicians spend countless hours coordinating care for patients with chronic conditions—but much of this labor has historically gone unacknowledged and without reimbursement.[]
This doesn’t have to be the case, however. There are several billing codes that physicians may be leaving on the table when it comes to managing chronic conditions. “These codes pay physicians for work they already do between visits but only a small percentage bill for them,” says Sirisha Bommireddipalli, CMPE, CHBC, CPC, CEO of MedConverge, who specializes in supporting independently owned healthcare practices.
Codes worth keeping on your radar
Chronic Care Management (CCM): CCM (99490) is the recurring-revenue engine for any physicians treating patients with two or more chronic conditions, explains Bommireddipalli. “Clinical staff can do the monthly work under general supervision and bill under the practice, so it doesn’t sit on the physician’s plate. Documentation is critical,” she says.
Transitional Care Management (TCM): Bommireddipalli says that TCM (99495, 99496) is the most overlooked code. “It’s the one I’d chase first,” she says. “It pays more than a standard follow-up and reduces readmissions, but practices miss it because they never learn that a patient was discharged. The fix is a discharge-notification workflow, not necessarily more staff.”
Behavioral Health Integration (BHI): BHI (99484) and Collaborative Care (99492–99494) codes help get clinicians paid for the behavioral health work that primary care already does. “Start with BHI, and then grow into Collaborative Care once you have the care manager and psychiatric consultant,” Bommireddipalli suggests.
Principal Care Management (PCM): PCM (99424–99427) can be billed when patients with a single, very serious, high-risk condition are too sick to ignore but don’t qualify for CCM.
Advanced Primary Care Management (APCM): APCM G0556–G0558 is one of Medicare’s newest codes. “It’s a flat monthly bundle, not time-based, so it removes the minute-tracking that trips up CCM and PCM,” says Bommireddipalli. “It’s mutually exclusive with CCM, PCM, and TCM for the same patient in a month, so the question is which model fits the panel, not how to stack them. [It’s for] primary care only, so it fits your primary care groups and FQHCs, not specialty practices.”
A look at the G2111 add-on code
The options don’t stop there. Clinicians should also be aware of the new G2211 add-on code,[] which allows physicians to document the work associated with treating patients with complex, chronic care needs. Physicians can bill this code on top of standard Evaluation and Management (E/M) codes—but it seems this one is collecting dust as well.
According to Medical Economics, physicians must show that they’re advancing an ongoing care plan and that they are responsible for a patient’s health over time. Components of this activity might include adjusting medications, considering outside medical records, coordinating referrals, or considering treatment options applicable to multiple conditions.[]
It’s worth noting that G2211 can be billed with modifier 25 on the same day as your patient’s annual wellness visit or a vaccine administration, or during any Medicare Part B preventive service.[]
When utilized appropriately, all of these codes can protect margins for independent practices. “The physicians who get the most from these codes treat them as the operating backbone of value-based care, not a side-billing play,” Bommireddipalli says.
Related: 4 biggest risk factors for chronic disease, according to science