Small Practices Benefit Less from Medicare’s Care Management Codes

CMS added two care management codes to the Medicare Physician Fee Schedule to better support primary care practices, but a study from Harvard University suggests that the codes may not be working as expected.

The study published in the May edition of Health Affairs found that adoption rates for the transitional care management (TCM) and chronic care management (CCM) codes were low as of 2016, with smaller physician practices using the billing codes far less frequently than their large counterparts.

Researchers also found that over a fifth of all TCM claims and nearly a quarter of all CCM claims billed to Medicare by a practice in 2016 were not the beneficiary’s assigned primary care practice.

The findings raise concern about whether Medicare’s care management codes truly support primary care as originally intended when the program added the codes in 2013 and 2015, respectively, researchers stated.

The TCM code was designed to help providers transition Medicare beneficiaries from the home to the home by allowing physicians to bill the program for non-face-to-face and other care coordination services, such as telephone calls to the patient after discharge, discharge document reviews, and test follow-up.

Meanwhile, the CCM code pays physicians for enhanced care coordination efforts for Medicare beneficiaries with multiple chronic conditions. It specifically reimburses physicians for developing a care management plans, as well as providing at least twenty minutes of non-visit-based services per month (e.g., reviewing lab results, communicating with specialists, or making adjustments to a patient’s treatment regimen), which can be provided by physicians or their supervised clinical staff members.

CMS expected the codes to be a potentially important source of additional revenue for primary care practices in particular. Primary care physicians have long criticized the Medicare Physician Fee Schedule for failing to value their services appropriately, many of which non-visit based.

However, evidence has demonstrated that physicians do not use the care management codes frequently.

According to a 2018 study, TCM and CCM services were provided to just 9.3 percent and 2.3 percent of potentially eligible beneficiaries, respectively. Another analysis that year also found that only about half of primary care physicians are aware that Medicare will reimburse them for chronic care management services.

But the problem with the care management codes may be deeper than low adoption rates, the study from Harvard indicated.

The researchers at Harvard studied a random 20 percent sample of fee-for-service Medicare claims and enrollment data for 2016 and compared the data to trends from the 2010 to 2016 period. They found that 11,430 practices billed for at least one TCM service and 3,847 practices billed for at least one CCM service in 2016. Of those, 10,384 practices billing for at least one TCM and 3,347 practices billing for at least one CCM service that year were primary care practices.

The primary care practices billing Medicare using either a TCM or CCM code were larger – 18.5 percent of TCM practices had eleven or more physicians versus 7.0 percent of non-TCM practices, as did 18.8 percent of CCM practices versus 8.8 percent of non-CCM practices.

The practices also had more Medicare beneficiaries per primary care physician (49.3 percent of TCM practices were in the top tertile versus 28.1 percent for non-TCM practices, as were 51.2 percent of CCM practices versus 31.3 percent of non-CCM practices) and more likely to be participating in an ACO (23.7 percent of TCM practices versus 12.4 percent of non-TCM practices, and 24.5 percent of CCM practices versus 14.1 percent of non-CCM practices).

However, 21.2 percent of all TCM claims and 23.7 percent of all CCM claims were billed by a practice other than a Medicare beneficiary’s assigned primary care practices, researchers found. These practices were largely multispecialty practices that were often affiliated with or part of a larger hospital system, specialty practices, and practices that specialize in providing institutionally based services, such as post-acute care services or home-based services.

In comparison, over 90 percent of annual wellness visits were billed by an assigned primary care physician, researchers reported citing a 2018 Harvard Medical School analysis.

Several factors may explain the findings, including the fact that larger practices have more beneficiaries eligible for the care management codes and may be better equipped to deliver non-visit-based services. But smaller practices still appear to be less likely to benefit from the new codes, researchers stressed.

CMS altered several of the requirements of CCM in 2017 to promote greater uptake among practices. Whether the changes improved adoption as expected remain to be seen.

In the meantime, researchers advised CMS to consider streamlining rules, including documentation requirements, encouraging other payers to adopt the codes, and eliminating cost-sharing for the codes, which may hinder some practices from using the codes. CMS may also consider auditing the use of the codes by non-primary care practices or modifying the regulations to limit the types of providers who can bill Medicare using the codes, they stated.