After Years of Advocacy Spearheaded by AGS, Medicare
Beneficiaries to Get Care Coordination Services
In a key development championed by the AGS and the American Medical Association (AMA), and supported by leading healthcare organizations, the Centers for Medicare and Medicaid Services (CMS) announced this month that it will pay qualified healthcare professionals for coordinating Medicare beneficiaries’ transitions from inpatient to outpatient settings. The policy was published in CMS’ 2013 Final Physician Fee Schedule Rule on November 1. It takes effect January 1.
The new policy, for which the AGS has long advocated, is designed to reduce the frequency with which beneficiaries are readmitted to hospitals and skilled nursing facilities or need emergency department care. Roughly one in five Medicare patients is readmitted within a month of being discharged from an inpatient setting. In 2005, MedPAC estimated the cost of these readmissions at $15 billion annually.
Under the new policy, healthcare providers coordinating care for patients undergoing transitions of care will be responsible for communicating with all of the healthcare providers and agencies involved in a given patient’s care. These clinicians will also be responsible for monitoring and reconciling patients’ discharge medications with their previous regimens to lessen the likelihood of adverse drug events during transitions. The codes cover all non-face-to-face services related to the discharge that are performed by the physician or other qualified health professional and clinical staff, during the 30 days following discharge, as well as a single face-to-face visit occurring after discharge. The codes are to be used only for moderate or high-complexity patients with multiple comorbidities who take multiple medications, and are at high risk of deterioration.
“This important new policy is a testament to the hard work of our members, the AMA, and the many other organizations from multiple disciplines who worked tirelessly with us toward this goal,” said AGS Board Chair Barbara Resnick, PhD, CRNP. “It’s also a testament to CMS’ commitment to enhancing the care of older adults. Working together, we’ve effected a change that will greatly benefit many of our most vulnerable patients.”
The AGS’ efforts to improve transitions of care go back to 2001. That year, the society launched an ongoing, wide reaching effort to ensure that Medicare beneficiaries get coordinated care when needed-- including when negotiating transitions of care. To make this most recent accomplishment a reality, AGS worked closely with the AMA’s RUC/CPT Chronic Care Coordination Workgroup (C3W) to develop Medicare’s two new transitional care management (TCM) codes, which were then approved by AMA’s CPT Editorial Panel. The society then led a multidisciplinary group of 14 other healthcare professional organizations that worked through the AMA’s Relative Value Scale Update Committee (RUC) process to value the new codes. A number of key developments helped move the process to completion.
At the same time that the AGS, AMA, and other organizations were developing the two TCM codes, they were also developing three additional codes for complex chronic care coordination (CCCC) services for the most vulnerable beneficiaries. These codes are designed to cover the time and work that healthcare professionals invest when, for example, working face-to-face with patients, developing care plans, identifying community resources for patients and caregivers, and providing caregiver education. While the RUC approved both the CCCC codes and the TCM codes, CMS did not include the CCCC does in the Final 2013 Physician Fee Schedule Rule. As a result, Medicare will not compensate healthcare providers for offering CCCC services at this juncture, though private, commercial insurers may opt to do so.
“In light of this, the AGS plans to continue working collaboratively with the agencies and organizations with which it partnered in the successful effort to incorporate TCM codes into the fee schedule -- in hope of seeing the CCCC codes added to the 2014 Physician Fee Schedule,” said AGS CEO Jennie Chin Hansen. “The TCM and CCCC codes complement one another. While the goal of TCM is to prevent rehospitalization, the goal of the CCCC is broader. It’s designed to efficiently integrate care, maximize the patient’s functioning and wellbeing, and prevent hospitalizations. Incorporating these three new codes into the 2014fee schedule, in addition to the new TCM codes, will go even farther in improving outcomes for vulnerable patients, enhancing outcomes, and reducing costs.”
