CMS increases reimbursements for complex patients according to study

CMS increases reimbursements for complex patients according to study May 29, 2018

Physicians who see patients with chronic and complex conditions often spend time outside the office visit engaging both with that patient and with other healthcare providers treating the patient. Until recently, those physicians were not reimbursed for the additional time they spent with chronically ill patients. However, a study recently conducted by the Urban Institute, and supported by the Robert Wood Johnson Foundation, explains that the Centers for Medicare & Medicaid Services (CMS) has initiated new primary care billing codes for physicians who care for patients with chronic conditions.

The report states that, “in creating this new billing code, CMS acknowledged that the existing payments for some patient visits did not provide sufficient compensation to cover all the prep and follow-up work required for such visits.” Recognizing that complex patients are costly – 69 percent of traditional Medicare beneficiaries have multiple chronic conditions, yet they generate 93 percent of Medicare spending – CMS is placing a higher priority on their care.

The shift to quality care requires primary care physicians to focus on outcomes, which also requires spending more time with complex patients. The new billing codes and demonstrations implemented by CMS allows the organization to: “(1) incentivize specific activities that the agency knows it wants clinicians to engage in (through billing codes), and (2) test whether it can achieve favorable outcomes by paying for promising new delivery reforms (through demonstrations),” according to the Urban Institute study.

The primary care-friendly billing codes are reflected in the final rule for the 2018 Medicare Physician Fee Schedule (PFS). As the report states, “Medicare will now pay for time spent engaging in remote monitoring of patients’ physiological data (e.g., blood pressure, glucose; 99091) and for a variety of telehealth services (e.g., caregiver health risk assessments [96161], care planning for chronic care management [G0506], and interacting with complex patients [90785]).”