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2015 Medicare fee schedule includes chronic care billing code, Sunshine Act changes


Additional telehealth services would also be covered

Beginning next year, primary care physicians and others could begin billing separately for chronic care management (CCM) services if the Physician Fee Schedule (PFS) proposed by the Centers for Medicare and Medicaid Services (CMS) is adopted. 

CMS announced the proposed rule containing updates to the PFS July 3. The rule also adds several services that Medicare could cover under its telehealth benefit, and makes changes to some of the disclosure provisions in the Physician Payment Sunshine Act.

The proposed rule does not include any PFS updates tied to the sustainable growth rate (SGR) formula because "these calculations are determined under a prescribed stautory formula that cannot be changed by CMS," according to a CMS fact sheet.

The proposed rule establishes a code with a payment rate of $41.92 that could be billed no more than once per month per qualified patient for Medicare beneficiaries with “multiple, significant chronic conditions (two or more),” according to CMS. The agency defines chronic care management as including:

  • regular development and revision of a plan of care,

  • communication with other treating health professionals, and

  • medication management

In addition, the rule would allow more flexibility in supervising clinical staff providing CCM services. Reversing a proposal from last year, practitioners and practices would not have to meet separate standards in order to furnish CCM services under the rule.

Next: Which telehealth services would be covered?


Telehealth services CMS proposes to cover under Medicare include:

  • annual wellness visits,

  • psychoanalysis,

  • psychotherapy, and

  • prolonged evaluation and management services

The American Academy of Family Physicians (AAFP) praised the introduction of a separate billing code for CCM services, while criticizing Congress for its unwillingness to fix the SGR formula so that physicians are not under constant threat of dramatic cuts in Medicare reimbursements.

Reid Blackwelder, MD, FAAFP"This code recognizes the value of additional cognitive and administrative work that occurs outside the exam room but that is essential to comprehensive, coordinated care," Reid Blackwelder, MD, FAAFP, president of the AAFP said in a prepared statement. "The AAFP welcomes the new code but we also look to a day when policies designed to strengthen primary medical care are not undermined by drastic cuts to the underlying foundation on which all payment is based. We again call on Congress to repeal the flawed sustainable growth rate formula reflected in the 2015 proposed Medicare physician fee schedule."

In March Congress appeared poised to repeal the SGR formula, but the effort foundered at the last minute over the question of how to pay for it. It is widely expected that the effort will continue in the coming months.

Congress appeared poised in late March to finally repeal the much-reviled

Sustainable Growth Rate (SGR) formula

used to calculate Medicare reimbursements. At the last minute, however, the repeal effort foundered over the question of how to pay for it. - See more at:

Regarding the Sunshine Act, CMS is proposing, among other changes, to begin requiring disclosure of payments drug and medical device manufacturers make to speakers at certain continuing medical education (CME) events. CME events previously had been exempted from Sunshine Act reporting requirements. Eliminating the exemption “will create a more consistent reporting requirement, and will also be more consistent for consumers who will ultimately have access to the reported data,” according to CMS.

The proposed rule will be published in the Federal Register on July 11. CMS will accept comments until September 2.



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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health