Medicare Physician Services: Spending On and Use of Billing Codes for Comprehensive Care Planning Services
Released: 2019-07-31T00:00:00

Letter

Background

Medicare’s Physician Fee Schedule

CMS uses the Medicare Physician Fee Schedule to pay physicians and other providers for services delivered to beneficiaries. Physicians and other providers bill Medicare for their services using various five-digit billing codes based in part on codes developed by an AMA panel. Each year, the panel receives proposals from provider groups and others to revise existing billing codes or create new codes. The panel requires those who submit proposals to develop a clinical vignette that describes the typical patient who would receive the service, the diagnosis and relevant conditions, and estimates of time that physicians might spend in providing the service for the typical patient. The panel applies several criteria in reviewing these proposals. For example, a new code should represent a unique, well-defined procedure or service clearly identified and distinguished from existing procedures and services; should not fragment an existing procedure or service represented by one or more existing codes; should reflect the typical (not extraordinary) circumstances related to the delivery of the service; should be performed by many physicians or other qualified health care professionals across the United States; and should be consistent with current medical practice.

CMS pays providers a fixed amount known as the Medicare fee for each code. The fees are based on relative values—estimates of resources for the physician’s work (time, skill, and level of training), and practice expenses (the costs of running a practice such as salaries of non- physician employees, rent, and overhead) required to provide a service relative to all other services. In setting fees, CMS also does not allow certain codes to be billed together if it deems that payment for one code is already included in another. CMS establishes and updates relative values annually. By law, the effect of any changes to its payment rates generally must be budget neutral. That is, if total spending increases by more than $20 million each year, including due to the creation of new billing codes, fees for all services would have to be reduced accordingly.

Services billed under the physician fee schedule may be provided in a variety of settings, including physicians’ offices and institutional settings such as hospitals, skilled nursing facilities and hospices. Non-physicians may also bill or be reimbursed by Medicare for services under certain circumstances. For example, some types of non-physicians practicing independently—such as physician assistants and nurse practitioners— may bill Medicare for certain services that they are legally authorized to perform under their respective state laws. In other instances, physicians may bill as if they had furnished services that were provided by non- physician staff that they employ or with whom they have a contractual relationship as long as the physician has an established relationship with the beneficiary, and is on the premises to provide supervision if necessary.

Care Planning Services in Medicare

Providers and other stakeholders have noted that they care for an elderly population with increasingly complex medical conditions who receive care from multiple providers across different sites of care including physicians’ offices, hospitals, nursing homes, and hospices. As such, the focus of primary care has shifted from treating specific medical conditions to increased care coordination and planning. CMS also noted that a new trend in care planning is the use of shared care plans between the beneficiary and the provider rather than those created solely by the provider. These jointly developed care plans can be particularly important to improving overall beneficiary outcomes for beneficiaries with serious illnesses and also allow other providers involved in the beneficiary’s care access to timely information that supports planned care.

However, stakeholders have suggested that Medicare’s payment system does not fully reimburse providers for such care planning services. For example, some note that the E/M billing codes that primary care physicians generally use to bill for their services were developed at a time when care coordination and planning was not part of the standard practice of medicine; as such, these codes do not reflect time spent on activities that do not require a face-to-face encounter with the beneficiary, including medical conferences with other physicians, or telephone calls to coordinate care with other providers. Some primary care physicians have requested that CMS conduct a comprehensive review of existing E/M codes to ensure they account for time spent on these services, or develop new codes that primary care physicians may exclusively use to bill for these services. However, others have noted that E/M codes have been reviewed and valued by the AMA, and the codes account for the time spent on these services. Moreover, they have stated that care coordination and planning services are delivered by multiple specialties, not just primary care physicians.

Medicare’s Physician Fee Schedule Contains at Least 58 Billing Codes That Providers May Use to Bill for LCCP-Type Services

Our analysis identified at least 58 Medicare Physician Fee Schedule billing codes that providers may use to bill for LCCP-type services. These 58 billing codes generally contain components we determined to be equivalent to the five key components of the LCCP service as defined in the 2018 BBA. For example, all 58 codes included a provision for the development of a care plan that addresses the beneficiary’s goals, values, and preferences, and a provision for coordination with other providers, which is equivalent to the LCCP component related to interdisciplinary care. Providers may choose a single code or a combination of these codes to account for the time, skill, and resources needed to deliver the service based on the unique health needs of each patient. (See app. IV for more information on the 58 codes and the LCCP components they contain as defined in the 2018 BBA.)

The 58 billing codes for LCCP-type services include 45 longstanding, broadly-defined codes and 13 narrowly-defined codes that were more recently introduced starting in 2013.

Broadly-defined codes. Of the 45 broadly-defined codes, 39 are E/M codes that have existed for decades. E/M codes are broadly defined to include services provided to treat a variety of illnesses (for example, treatment of a particular medical complaint), but they may also be used to bill for LCCP-type services. In general, the E/M codes range in complexity from low to high depending on the amount of time the provider spends with a patient as well as the complexity of the medical condition(s) being treated. E/M codes may also be billed if more than 50 percent of the time allotted for the service is spent on counseling and care coordination—for example, explaining treatment options and ways to mitigate the patient’s health risks—which are key components of the LCCP service as defined in the 2018 BBA.

The E/M codes we identified as representing LCCP-type services were the more complex codes that had estimates of time that may be spent providing the service to a typical patient ranging from 30 to 120 minutes of physician time and 3 to 71 minutes of non-physician time. While the majority of E/M codes have existed for decades, CMS added six new E/M codes starting in 2008—referred to as “prolonged” E/M codes—allowing payment for additional time for care planning and care management services for complex conditions.

Narrowly-defined codes. Starting in 2013, CMS added 13 narrowly- defined LCCP-type codes to better account for the time spent coordinating care for patients with complex treatment needs. CMS implemented these more narrowly-defined care planning codes largely in response to provider complaints that E/M codes did not sufficiently account for extensive care management/coordination of care that was required across multiple providers and settings. Unlike broadly-defined codes, these narrowly-defined codes can only be used for LCCP-type services.

The 13 narrowly-defined LCCP-type codes fall into four types: transitional care management (TCM), chronic care management (CCM), advance care planning (ACP), and behavioral health integration (BHI). (See table 1.) While some pertain to patients with specific types of health conditions or in certain settings, others are more general and may be used for a range of health conditions.

The estimates of physician and non-physician time that may be spent on the broadly-defined and narrowly-defined codes vary, as does Medicare’s 2019 fees for these billing codes—see examples of commonly used LCCP-type billing codes in table 2 and see appendix IV for related information on all 58 LCCP-type billing codes. For example, some stakeholders told us they might bill a complex E/M code (99214) along with a CCM code (99487). As our analysis shows, this combination could result in the provider spending 66 minutes of physician time and 113 minutes of non-physician time for a typical beneficiary, and receiving total Medicare fees of about $203 in 2019.

Medicare Spending Increased for All LCCP-Type Services and Increased More Rapidly for New Narrowly-Defined Services That Were Furnished to More Beneficiaries by More Providers

Medicare Spending on All LCCP-Type Services Increased by 11 Percent from 2013 through 2017, While Spending on Narrowly-Defined Services Grew More Rapidly

Overall Medicare spending on LCCP-type services represented by the 58 billing codes we identified increased from $26 billion in 2013 to $29 billion in 2017, an 11 percent increase. The vast majority of this spending— about $28.3 billion in 2017—was on services represented by the 45 broadly-defined codes we identified earlier (henceforth we refer to these services as “broadly-defined services.”) By comparison, Medicare spending on LCCP-type services represented by the 13 narrowly-defined codes (henceforth referred to as “narrowly-defined services”) was about $467 million in 2017.

Though smaller in terms of total dollars, spending on narrowly-defined services grew at a higher rate than spending on broadly-defined services, from about $2 per beneficiary in 2013 to $14 per beneficiary in 2017. This higher rate in growth can mostly be attributed to these four new types of services being introduced during this 4 year period. For example, as Table 1 shows, two TCM codes were introduced in 2013 and four CCM codes were introduced from 2015 to 2017. In contrast, spending growth for broadly-defined services was much smaller, increasing from about $785 per beneficiary in 2013 to $844 per beneficiary in 2017. For all other Medicare Physician Fee Schedule services combined, per-beneficiary spending decreased from about $1,488 in 2013 to $1,426 in 2017.

Spending on CCM and TCM services accounted for most of the total spending on narrowly-defined LCCP-type services from 2013 to 2017. (See fig. 1.) For example, in 2017, TCM services accounted for almost half ($213 million of the total spending of $467 million), while spending on CCM services accounted for over a third ($162 million of the $467 million).

The growth in spending on narrowly-defined services was driven by increased utilization—that can be attributed in part to the development of new codes for these services—rather than increases in Medicare fees for these services. Specifically, utilization of narrowly-defined services increased from about 9 services per 1,000 beneficiaries in 2013 to about 177 services per 1,000 beneficiaries in 2017. Average Medicare fees for these services remained flat during this period.

More Beneficiaries Received and More Providers Billed for Narrowly-Defined LCCP- Type Services, with a Small Share of Beneficiaries and Providers Accounting for Most of the Services

The number of beneficiaries receiving narrowly-defined LCCP-type services increased substantially from 2013 to 2017, as more of these Medicare billing codes were added and began to be utilized during this time. Specifically, in 2017, about 2.5 million beneficiaries received narrowly-defined LCCP-type services, representing an 839 percent increase from about 267,000 beneficiaries in 2013. (See fig. 2.)

While the overall number of beneficiaries receiving narrowly-defined services increased, these services were concentrated among a relatively small share of Medicare beneficiaries. Specifically, one-quarter of beneficiaries who received any of the narrowly-defined services in 2017 received 62 percent of the approximately 6 million services that were provided that year. (See fig. 3.)

In 2017, of the total 2.5 million beneficiaries that received narrowly- defined services, 90 percent received only one type of narrowly-defined LCCP-type service. (See fig. 4.) In contrast, only 10 percent of beneficiaries received multiple types of narrowly-defined LCCP-type services, the most common combination being CCM and ACP.

Mirroring beneficiary trends, the number of Medicare providers billing for narrowly-defined LCCP-type services also increased significantly from 2013 through 2017, as these Medicare billing codes were established and began to be utilized during this time. In 2017, a total of about 100,000 providers billed for narrowly-defined services, representing a 227 percent increase from about 31,000 providers in 2013. (See fig. 5.)

As with beneficiary trends, while the overall number of providers billing narrowly-defined services grew from 2013 to 2017, billing for these services was also increasingly concentrated among a small share of providers. Specifically, in 2017, 10 percent of providers who billed for any narrowly-defined services billed about 76 percent of the approximately 6 million services that were provided in that year. (See fig. 6.)

Each year from 2013 through 2017, physicians specializing in internal medicine accounted for the largest share of spending on narrowly-defined LCCP-type services. In 2017, internal medicine accounted for 45 percent of the $467 million in total Medicare spending on narrowly-defined services. (See fig. 7.) Family practice and nurse practitioners were the other specialties accounting for the greatest shares of spending.

In terms of the setting in which narrowly-defined LCCP-type services were provided, the majority were provided in nonfacility settings such as physicians’ offices. Specifically, in 2017, 94 percent of narrowly-defined services were provided in nonfacility settings. This trend was consistent over each of the 5 years from 2013 to 2017.

Stakeholders Had Mixed Views on Whether a New Billing Code for an LCCP Service Is Needed

Six Stakeholders Did Not Support Creating a New Billing Code for an LCCP Service

Six of the 19 stakeholders we interviewed did not support the creation of a new billing code for an LCCP service as defined in the 2018 BBA. Two of these—representing physician specialties that together accounted for almost one-fifth of total spending on LCCP-type services in 2017—stated that the existing billing codes were sufficient for them to provide and bill for the full range of the LCCP service. They stated that billing either a single code or a combination of an E/M code and one or more of the 13 narrowly-defined LCCP-type codes we identified allowed them to account for the full range of the LCCP service as defined in the BBA. As such, the two stakeholders said, there was no need for a new billing code.

The remaining four stakeholders expressed concerns about creating a new billing code for an LCCP service. These concerns included the following:

Overlap with existing codes that require the development of care plans: While not explicitly stating that existing codes were sufficient, some stakeholders said that if a new billing code were created for the LCCP service as defined in the 2018 BBA, it would overlap with or duplicate existing billing codes. For example, three stakeholders noted potential overlap with existing billing codes, such as the ACP and CCM. Three stakeholders said that the care plan that would be required under the new LCCP code would duplicate existing care plans that are required by law for beneficiaries in hospices or skilled nursing facilities. In addition, two stakeholders noted that providers in their specialty already prepare detailed care plans as a standard practice of care when evaluating their patients and billing for these services using existing E/M billing codes. They stated that these care plans exceed the components of the care plan specified in the 2018 BBA. Stakeholders noted that the existence of multiple overlapping codes that include the development of a care plan could create confusion for providers in choosing the most appropriate billing code.

Concerns about code proliferation or code fragmentation: Several stakeholders were concerned that adding another code to Medicare’s billing system could result in increased Medicare spending and less, rather than more, care coordination. Specifically, two stakeholders stated that having multiple billing codes for care planning and care management, respectively, would have the potential to increase spending because multiple providers could start billing the new codes even though one provider may have primary responsibility for the beneficiary. (In contrast, under the existing billing codes a single code that encompassed both types of services could be billed.) For example, one of these stakeholders said that primary care physicians generally referred beneficiaries with complex treatment needs to a surgeon or specialist who then both planned and managed the beneficiary’s care, yet the primary care physician might also bill the care planning billing code. In addition to the potential for increased Medicare spending, three stakeholders said that code fragmentation—splitting existing billing codes into multiple codes for services that were previously bundled together—was contrary to the comprehensive patient-centered model of care that Medicare was moving towards. Specifically, one provider stated that under such a model, rather than billing multiple different codes for care planning and coordination, a primary care practice is paid a monthly management fee to (among other things) improve care coordination for patients who receive most of their primary care services from that practice.

Thirteen Stakeholders Stated That a New LCCP Code Could Address Concerns Regarding Interdisciplinary Care Reimbursement and Other Limitations They Identified in Existing Billing Codes

While six of the stakeholders we interviewed did not support creating a new LCCP code, the remaining 13 stakeholders told us that such a billing code is needed. According to the stakeholders, a new LCCP code as defined in the 2018 BBA could address several concerns they identified in Medicare’s existing billing codes related to the provision of the LCCP service. However, some of these concerns could be addressed under the current Medicare billing framework, as shown by our analysis of available data. For example, stakeholders identified the following limitations that could be addressed by a new LCCP code: Inadequate reimbursement for time spent on interdisciplinary care: The 13 stakeholders stated that Medicare’s existing billing codes either did not require or did not sufficiently reimburse them for the time spent on interdisciplinary care. They stated there should be a separate code to reimburse this type of care. However, stakeholders representing two specialties told us they had proposed such a code to the AMA but the AMA had rejected their proposals because interdisciplinary care is already accounted for in the existing billing codes. Moreover, as our analysis of the 58 billing codes shows, the majority of these codes include a provision for consultation and coordination among providers that is equivalent to input from an interdisciplinary team. With regard to inadequate reimbursement, as another stakeholder noted, providers may bill a complex E/M service along with a narrowly-defined LCCP-type service such as CCM. The total reimbursement for such a combination of codes would be about $203 as of 2019. (See table 2.)

Insufficient physician time for care planning: Six stakeholders representing a mix of primary care and medical specialties stated the existing billing codes (including the more complex E/M codes) had insufficient physician time to provide both care planning and care management, which they maintained are separate and distinct activities. They stated a new code could include the appropriate time needed. One stakeholder said that care planning requires at least 30 minutes of time, and the complex E/M codes do not allow providers to bill for the time it takes to provide both the care management of a complex patient as well as care planning for the patient. According to the stakeholder, for example, if a provider bills a complex E/M code that allows for 40 minutes of physician time, that is insufficient to provide both types of services. While CMS has recently established new prolonged E/M codes (which allow for an additional 60 minutes of time), the stakeholder noted that they do not address the problem of insufficient time because a prolonged E/M code may only be billed with a companion E/M code, and the threshold of time needed to bill the two codes together is now too high—specifically 40 minutes for the complex E/M code plus 60 minutes for the prolonged E/M code. However, our review of CMS guidance on billing of prolonged E/M codes shows that providers do not have to meet the full 60 minutes of time in order to bill a prolonged E/M code; they may bill it as long as the total time spent on the visit exceeds the typical time for the E/M visit plus 30 minutes.

Documentation requirements: Three stakeholders, largely representing primary care and medical specialties, stated that burdensome documentation requirements for the more complex E/M codes hampered their ability to bill these codes. They suggested that a new billing code could be structured similar to the new ACP or CCM codes which do not have the same documentation requirements. While these stakeholders expressed concern regarding documentation as a discouraging factor, our analysis of 2017 Medicare claims data showed that certain specialties, including some that had expressed this concern, billed the more complex codes at a significantly higher rate than the average across all specialties. This may indicate that these documentation requirements do not necessarily preclude providers from billing these codes. For example, 83 percent of all the E/M new patient visits billed by geriatricians in 2017 were billed using the more complex E/M codes, compared to 48 percent on average. Similarly, 80 percent of all the E/M established patient visits billed by clinical psychologists in 2017 were billed using the more complex E/M codes compared to 50 percent on average. See appendix V for details on billing patterns for all medical specialties.

Inability of non-physician staff to independently bill for care planning: Seven stakeholders expressed concerns that non-physician staff such as nurses and social workers cannot independently bill the existing Medicare billing codes that we identified as being LCCP-type services. As one stakeholder explained, non-physician staff may spend time providing coordination and care planning services separately rather than concurrently with the physician, but they cannot bill for this time independently because the physician was not present. These stakeholders stated that a new LCCP code that could be billed by physicians and non-physicians that participated in the care planning process could address this issue. However, other stakeholders expressed concerns about the effect on Medicare spending if multiple providers billed for an LCCP service. Moreover, reimbursement for non-physicians is built into Medicare fees. Specifically, Medicare’s fee for each billing code includes reimbursement for physician’s time as well as their practice expenses (which cover the costs of non-physician staff), and when the AMA panel develops resources estimates for each billing code (upon which Medicare fees are based), it considers the amount of non-physician time spent on that code. Certain non-physician practitioners, such as nurse practitioners and physician assistants, may also independently bill services under the Medicare Physician Fee Schedule subject to certain requirements, and as specified in their scope of practice under state law.

Stakeholders generally concurred that if a new LCCP code were implemented, the definition of interdisciplinary care should be flexible and not require a social worker. Currently, the LCCP billing code as defined in the 2018 BBA requires that the interdisciplinary team providing care planning services include a social worker. However, 13 stakeholders stated that a typical practice did not include a social worker, but rather included a nurse who might perform the functions of a social worker. They stated that smaller office-based medical practices could not afford to hire a social worker. The stakeholders concurred that social workers were generally available in larger integrated practices (such as a single or multiple groups aligning with each other or with a larger hospital system) and in facility settings such as hospitals or skilled nursing facilities. (Stakeholders also provided other comments on the structure of a potential new billing code for the LCCP service should such a code be established by CMS, which we summarize in app. VI.)

Agency Comments

We provided a draft of this report to HHS for review and comment. HHS provided technical comments, which we incorporated as appropriate.

We are sending copies of this report to the appropriate congressional committees, the Secretary of Health and Human Services, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7114 or farbj@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix VII.

Appendix I: Example of an American Medical Association Vignette

Appendix II: Longitudinal Comprehensive Care Planning Service Components in the Balanced Budget Act of 2018

Appendix II: Longitudinal Comprehensive Care Planning Service Components in the Balanced Budget Act of 2018 Pub. L. No. 115-123, § 50342(c)(4), 132 Stat. 211.

Appendix III: Stakeholder Groups Interviewed by GAO

Appendix IV: Medicare Physician Fee Schedule Billing Codes for Longitudinal Comprehensive Care Planning (LCCP)-Type Services

We identified 58 billing codes in Medicare’s physician fee schedule that may be used to bill for LCCP-type services as defined in the Balanced Budget Act of 2018 (2018 BBA). Figure 9 shows relevant information on these billing codes including the short descriptor, beneficiary eligibility criteria, our analysis of whether the billing code’s components are equivalent to the components of an LCCP service as defined in the 2018 BBA, and Medicare’s 2019 fee.

Appendix V: Specialty Billing of Complex Evaluation and Management Codes in 2017

Medicare’s physician fee schedule contains evaluation and management (E/M) codes that providers may use to bill for face-to-face visits in their offices or other settings such as hospitals. These codes range in complexity from low to high depending on the amount of time the provider spends with a patient as well as the complexity of the medical decision- making and the medical condition(s) being treated. Table 4 shows the percentage of each specialty’s E/M visits that were billed as complex visits (moderate or high complexity). In general, primary care and medical sub-specialties tended to bill complex visits at a higher rate than the all- specialty average, while surgical specialties tended to bill complex visits at a lower rate than the all-specialty average.

Appendix VI: Longitudinal Comprehensive Care Planning (LCCP) Services: Stakeholder Perspectives on Potential New Billing Code

We interviewed 19 stakeholders including national umbrella groups of physicians and other providers to obtain their perspectives on the structure of a new billing code for LCCP-type services as defined in the Balanced Budget Act of 2018 (2018 BBA), regardless of whether they supported the creation of a new code. Stakeholders were generally in agreement that a new billing code for LCCP-type services as defined in the 2018 BBA, if implemented, should be broadly defined. Specifically, stakeholders stated that it should not be tied to a specific condition, should allow for both in-person and non-face-to-face services performed when the beneficiary was not present, should be billable more than once, should be available for billing by both primary care physicians and specialists, and should have restrictions to avoid duplicative billing with existing billing that provided overlapping services. However, stakeholders had more mixed views about what these specific restrictions should be. Stakeholder views about the various structural components or restrictions included the following:

Applicable medical conditions: The majority of stakeholders (13 of the 17 who responded to this question) stated that the new code should be broadly defined although they differed in their opinions of what broadly-defined meant; one stakeholder cautioned against an overly broad definition, and one suggested pilot testing with a discrete list of conditions.

Of the 13 stakeholders in favor of a broad definition, 12 stated that the new billing code should not be tied to any particular specific illness or medical condition but should be flexible in structure. Three stakeholders stated that the extent of beneficiaries’ daily functioning or quality of life should also be considered when defining applicable medical conditions. For example, a beneficiary who is not necessarily suffering from a life-threatening illness but is unable to perform the functions of daily living (such as bathing and eating) needs extensive care planning and should therefore be covered under the new LCCP-type service. Three stakeholders stated that the new code should be billable if a beneficiary’s existing diagnosis of a serious illness changed. Three stakeholders stated that a potential new code could be modeled along the lines of existing billing codes—specifically the advance care planning (ACP) or chronic care management (CCM) codes— which do not specify any particular medical condition.

Two stakeholders said that a new code should not be so broad that it could apply to a vast majority of beneficiaries. For example, one stakeholder stated that the American Medical Association would likely not approve a code for a generic serious condition because it would be difficult to differentiate that code from an existing billing code, such as an evaluation and management (E/M) code, which may be used for any medical condition including serious, life-threatening conditions.

One stakeholder suggested pilot testing the code with a discrete list of conditions, with the intention of expanding the list afterwards.

In-person or non-face-to-face: The majority of stakeholders (12 of the 15 that responded to this question) stated that a potential new code should allow for both in-person and non-face-to-face activities (such as virtual or telehealth—providing clinical care remotely by two-way video, phone calls with the beneficiary or to arrange referrals or coordinate care with other providers when the beneficiary was not present); three said it should only include face-to-face activities.

Twelve stakeholders stated that the visit should include both types of activities. For example, one stakeholder said the initial visit for LCCP-type services should be in-person, and follow up activities such as updating a care plan or remote patient monitoring (monitoring of patients outside of conventional settings) could be non-face-to-face.

Three stakeholders said it should only include face-to-face activities either because of concerns about the potential for overbilling if the new code included non-face-to-face activities which might be difficult to verify or because other existing codes, such as CCM, already cover non-face-to-face activities.

Frequency of billing: All of the 16 stakeholders responding to this question concurred that the new code should be billable more frequently than on a one-time basis, although opinions varied on the exact frequency.

Nine stakeholders said the code should be billable on an ongoing basis as the beneficiary’s condition changes. For example, one said that the new code should be on-going because the care planning and treatment would continue to evolve over time as the beneficiary’s condition changes.

Seven other stakeholders said that while it should not be an ongoing service, it should be billable more frequently than once. For example, one stakeholder specified that it could be billed once per month or over every three months, but that a target end date must be specified; otherwise, it would be too similar to existing billing codes such as the CCM code that may be billed monthly. Two other stakeholders said it could be billed up to 4-5 times a year.

Other billing restrictions: All 12 stakeholders responding to this question indicated that restrictions would be necessary to avoid overlap with existing billing codes. For example, three stakeholders suggested that the new code could be billed along with an E/M code for additional services not covered by the E/M code as long as it does not overlap with other existing codes that account for additional time beyond an E/M visit (such as the prolonged E/M visit billing codes). One suggested that it should not be billed along with any of the existing narrowly-defined LCCP-type codes, including CCM, transitional care management, or the ACP codes. One did not specify any particular code with which the new code should not be billed, but cautioned that care should be taken to ensure that time spent with the beneficiary was reported only once.

Providers eligible to bill the code: The majority of stakeholders (13 of the 15 that responded to this question) stated that both primary care physicians and specialists should be eligible to bill the new code. Two of these stakeholders said that there should also be a requirement that the billing physician has an established relationship with the beneficiary. Two stakeholders said that only specialists should bill since they are generally the ones attending to the beneficiary’s serious illness. Two stakeholders stated that non-physicians (including social workers) should also be able to bill the code as long as they are currently allowed to bill separately under the Medicare Physician Fee Schedule.

Appendix VII: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Karen Doran, Assistant Director; Iola D’Souza, Analyst-in-Charge; Sarah Belford; Krister Friday; John Lalomio; and Daniel Ries made key contributions to this report. Also contributing were George Bogart and Muriel Brown.