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New G-Codes to Pay Doctors for Broad Array of Non-Face-to-Face Care

 |  By cclark@healthleadersmedia.com  
   December 05, 2013

Though few physicians realize it yet, a new CMS rule will begin to pay them for the hours they and their clinical teams spend managing Medicare patients' chronic conditions beyond face-to-face office visits.

You've heard physicians complain about the hours of unpaid time they and their clinical teams spend managing their Medicare patients' chronic conditions beyond the face-to-face office encounters: The late-night and weekend phone calls, all the extra work.

The key word here is unpaid.

There are questions from patients and caregivers about diagnoses and dosages. Questions from referral specialists and pharmacists. Reviews of lab and imaging tests. Assessments of patients' functional status. Appointment coordination. Development of care plans. Doctors provide all that for free because none of it is compensated under Medicare's current rules, which consider these services part of the patient's prior or upcoming face-to-face visit.

All of this will soon change, although few physicians realize it yet.

The new G-code

Enter "G-code" for Chronic Care Management Services. The G stands for Government, as in the Centers for Medicare & Medicaid Services, which devised this code as a way to incentivize doctors to do a much better job coordinating their patients' care. In a news release, in fact, the agency called the G-code "a milestone."

As the agency spelled out in 44 pages of its final, 1,369-page Physician Fee Schedule rule last week, doctors will be able to bill separately for these types of non-face-to-face services starting Jan. 1, 2015. This is in addition to payment for evaluation and management (E/M) codes covering the face-to-face encounter. Although the G-code is valued at only 20 minutes of non-face-to-face activity per Medicare beneficiary every month, or roughly $30 depending on geographic or other pay adjustments, at least it's something.

"Overall we're very pleased," says Shari Erickson, vice president of governmental and regulatory affairs for the American College of Physicians, which represents 137,000 internists. Primary care practices are best poised to take advantage of this new revenue stream. "We've been asking CMS to pay for these services for quite some time, and CMS made a lot of changes from their original proposal that are more in line with what we're looking for."

Adds Reid Blackwelder, MD, president of the American Academy of Family Physicians, which represents 110,600 practitioners, "The G-code" is a good thing for patients and doctors, and definitely a step in the right direction."

Improving quality

In its November 27 rule, CMS officials specified that the agency now believes "successful efforts to improve chronic care management for these patients could improve the quality of care while simultaneously decreasing costs."

And it acknowledged the error of prior policies, saying that it realizes "the resources required to furnish chronic care management services to beneficiaries with multiple (that is, two or more) chronic conditions are not adequately reflected in the existing E/M codes."

While physician groups maintain that the doctors are doing this now anyway, and thank CMS for finally paying for it, perhaps a lot more is at stake. CMS is not just paying more, it also wants a more structured, systematic process within physicians' practices to make sure care coordination services are performed for these most complex patients. That's why they're now paving a way to pay for it.

CMS actually began paying physicians for non-face-to-face care in January 2013, but only for care coordination for patients transitioning from a hospital to a postdischarge setting or as spelled out in a few other limited pilot projects. "This [G-code] is much more significant in terms of the scope of the type of non-face-to-face services that they're going to be paying for," Erickson says.

The caveats

But of course, the rule imposes a few caveats regarding how G-codes can be used.

  • The patients eligible for G-code services must have two or more chronic conditions expected to last at least 12 months or until the patient's death and that place the patient at significant risk of death or functional decline.
  • The physician can bill for the services only once a month, but must document a minimum of 20 minutes doing this non-face-to-face activity each month. Even if the doctor's team spends five hours a month on these services, the payment will only be for 20 minutes.

Erickson says the ACP has concerns: The code won't generate enough to reimburse the practice for all the expenses incurred to provide the required non-face-to-face services, there will be additional documentation, and there could be the need for additional nurse practitioners or physician assistants to do much of this work on behalf of the practice.

  • The physician or another qualified eligible professional, such as an RN or a PA, can provide the service, but someone with clinical expertise has to be available 24/7, "regardless of the time of day or day of the week," according to the rule.
  • Because the service now becomes a billing claim, part of the cost will be paid with the patient's coinsurance under Medicare Part B at about 20%. Because of that, patients will have to give the physician consent to receive services billed under G-codes, and of course CMS will require documentation. This might be a problem if patients say no.
  • CMS put off two provisions contained in its proposed rule this summer. It dropped the requirement that individuals responding to 24/7 calls have access to the full patient record through an electronic health record. It also dropped the requirement that the practice be certified as a medical home. CMS indicated it will revisit those issues in future rules.

A physician in Kingsport, TN, Blackwelder says that primary care doctors like him don't get paid for reviewing all the pieces of paper that are put before them that require action for their patients.

"One thing to remember is that 37% of Medicare beneficiaries have four or more conditions, so these are extremely complicated patients," he says. "These are things we've already been doing, but I think we still have to figure out how to manage increasingly complex patients."

So how might CMS' change of heart improve quality of care? Erickson says much of the changes will involve reassignment of duties among staff who now perform coordination functions "on an ad hoc" basis, as time allows.

One example is that the RN may call the patient before the visit to clarify the patient's reason for coming in, she says. "If you identify what the patient wants to do before they get there, it cuts back on those last minute, 'oh, doctor, by the way' questions as the physician is walking out the door, but which were the reason the patient came in the first place," she says.

Other types of improved quality might include following up with referral specialists to make sure the patient was seen and what type of care ensued. Practices might block out time at the end of each day to accomplish some of these tasks that otherwise slip through the cracks.

"This is an on-ramp," Erickson says. "It gets some money in the door to provide consistent, systematic care coordination for patients with multiple chronic conditions." In time, she says, ACP will work to have such services rewarded even more, in line with the trend to pay for value rather than volume.

It's a work in progress, she says, "like trying to fix a plane while you're flying in it." Though few doctors are aware of the new provision, in coming months ACP will launch an educational campaign to get the word out. For now, doctors will have a year to prepare for it.

"We hope the G-code will have a significant impact," she says.


See Also: CMS Sets 2014 Pay Rates for Hospital Outpatient and Physician Services

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