CMSA: Medicare should pay for care services

Organization asks CMS to change reimbursement

The Case Management Society of America (CMSA) has requested that the Centers for Medicare & Medicaid Services (CMS) revise a recent ruling and make a number of care coordination services payable.

In its interim final rule for the 2008 Physician Fee Schedule, CMS created six assessment and care coordination CPT codes, which were assigned a relative value unit but were given an "N" status, meaning that they will not be reimbursed by Medicare.

Three of the codes pertain to telephone evaluation and management services provided by a physician to an established patient, parent, or guardian.

Three non-physician codes were issued for telephone assessment and management services provided by a qualified non-physician health professional, such as a case manager.

The codes specify that the services must not originate from a related assessment and management service provided within the previous seven days or lead to assessment and management services or a procedure within the next 24 hours.

In a letter to CMS, CMSA stated that the six codes would create incentives for assessment and management services that include transition of care coordination, medication reconciliation, health literacy, patient medication knowledge, readiness to change assessments, motivational interviewing, patient education, and medical home coordination.

"CMSA believes that by requesting funding support for these six codes, providers will more readily integrate case/care managers in the support of the care coordination concepts, such as the Medicare Medical Home Demonstration, pay-for-performance programs, and various collaborative care models, which CMS and other regulatory agencies are discussing," CMSA officials wrote in the letter to CMS.

The change will help every care manager provide better, more effective services to their patients, control costs for their organizations, and incentivize their companies in dedicating resources to solving care coordination issues, points out CMSA President Peter Moran, RN, C, BSN, MS, CCM.

CMSA is concerned that failure to provide financial reimbursement for those practices continues to misalign incentives and priorities that will negatively impact care delivery to patients, he adds.

"Currently, case managers work in a collaborative manner with physicians, pharmacists, and other care managers, such as social workers, to best coordinate patient care between different professionals and different practice settings. Without the appropriate financial funding for these types of services, health care providers have less incentive to provide this type of coordination and many cannot fund such initiatives on their own," adds Teri Treiger, RN-C, MA, CCM, CCP, CPUR, CMSA director and CPT committee project leader.

When the interim final rule was released in November, CMSA urged its members to write to CMS, asking the agency to provide failure reimbursement for the practices covered by the assessment and care coordination codes. The public comment period ended on Dec. 31.

"The good news is that we now have codes for care coordination. The next step is to get them reimbursable," Moran said.

Also in its interim final rule, CMS clarified the definition of covered case management and targeted case management services and added measures to address concerns about improper billing of non-Medicaid services by some states.

CMS defines case management as "services which help beneficiaries gain access to needed medical, social, educational, and other services." It defines targeted case manager services as those aimed at special groups of enrollees, such as those with developmental disabilities and chronic mental illness.

The new rule specifies that case management services include an assessment of an eligible individual, development of a specific care plan, referral to services, monitoring, and follow-up. It specifies that direct services, such as transporting a person to an appointment or court appearance, are not allowable.