CMS Puts Forward New Medicare Payment Reform Rule for Primary Care

by | Last updated May 17, 2023 | Published on Jul 25, 2016 | Medical Billing

New Medicare Payment
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The Centers for Medicare and Medicaid has released a proposed Medicare payment reform rule to update the Physician Fee Schedule and ensure better support primary care physicians. If this rule is finalized, it will ensure that more money goes into what matters: prevention, wellness, and mental health and chronic disease management.

Research published in the Journal of the American Board of Family Medicine (JABFM) found that though there are a large number of physicians specialized in treating specific chronic conditions in the outpatient setting, most patients seeking care for most of 14 high-cost chronic conditions were more likely to see a primary care physician than a specialist physician (69% vs. 24%, respectively). According to the authors, primary care physicians may be referred to as complex care physicians particularly are they are also responsible for identifying patient needs, offering preventive services, coordinating with community and public health resources, and facilitating behavior change.

The recently announced rule would update Medicare reimbursement rates and policies under the Physician Fee Schedule. In a press release the Acting Administrator of CMS explained that the new proposals are aimed at providing a significant lift to primary care practitioners and extending the time that they can spend with their patients “listening, advising and coordinating” physical and mental health care.

The new changes that CMS proposes which will bring about changes in family practice medical billing and coding include:

  • New medical coding and payment changes that would better pinpoint and value primary care, care management, and cognitive services.
  • Starting in 2017, separate reimbursements for some existing Current Procedural Terminology (CPT) codes that portray non-face-to-face prolonged evaluation and management treatments. Revaluation of CPT codes for face-to-face prolonged services is also on the anvil.
  • Separating payments using new codes that target care planning and assessments for patients with cognitive impairments as well as chronic care management for medically complex patients.
  • Implementation of new codes that take into account the increased costs for providing visits to patients with mobility-related challenges, especially for those with Medicare-Medicaid eligibility.
  • Support for behavioral healthcare by separating reimbursements for primary care practices that use coordinating care with a psychiatrist or mental health specialist for patients with behavioral health conditions.
  • Adjustment of Medicare reimbursement rates for potentially misvalued services by 0.51 percent in net expenditure reductions
  • Updating of reimbursement codes to account for new healthcare technology such as telehealth codes for end-stage renal disease-related service for dialysis and new codes to reflect current technology and digital imaging used in mammography services.
  • Expansion of the Diabetes Prevention Program to cover Medicare beneficiaries starting in 2018.

The rules are designed to ensure that beneficiaries receive medically necessary treatments from providers and suppliers that comply with Medicare programs. Healthcare providers and suppliers would need to be reviewed and enrolled in Medicare to contract with a Medicare Advantage organization and will also have to provide Medicare-covered items and service to beneficiaries in Medicare Advantage health plans.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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