Leveraging New Codes Can Make The Move to Value-Based Care a Little Easier

by | Apr 30, 2020 | Blog

Many providers consider the shift from the fee-for-service (FFS) reimbursement model to value-based care (VBC) as a significant burden on their organization, even though they understand the purpose: reducing costs, improving quality, and enhancing patient satisfaction (otherwise known as the Triple Aim). But there is another vantage point–one that has the potential for increasing revenue without needing to add patients to the daily roster.

This past November, the Centers for Medicare and Medicaid Services (CMS) issued their final proposed rules for services furnished under the Medicare Physician Fee Schedule for 2020. This includes provisions for remote patient monitoring (RPM) as well as for increased coverage for chronic care management (CCM). Under the new rules, general supervision is allowed for RPM, meaning third-party clinical partners can now provide RPM services to practices similar to the general supervision rules associated with CCM. New codes were also created for CCM that will fill the gap between the initial 20 minutes of clinical staff time per month and the 60 minutes for complex CCM time. Additionally, under the new rules, patients with only one chronic condition who do not qualify for CCM can now be managed under principle care management (PCM).

Now that these services are being reimbursed, providers can gain a two-fold benefit. The first is the opportunity to receive bonuses and reduce penalties. Secondly, CCM improves outcomes and patient satisfaction, which reduces readmissions and further increases reimbursement. The CMS will reimburse $42 per month per patient enrolled in a chronic care management plan. Research by the Annals of Internal Medicine found providers could capture $75,000 net revenue per provider per year if just half of their patients were enrolled in a plan. And this is with services provided by nurses or other non-physician clinicians.

Yet the fact remains that many providers see the opportunity as too resource-intensive, that the effort required outweighs the benefit. There are 35 million Medicare patients in the US who are eligible for CCM programs, but just a small fraction are enrolled in a plan. But the effort doesn’t have to be as hard as many believe. The secret is working differently, not harder. It just takes a new approach.

According to an article in Becker’s Hospital Review, “The current emphasis on productivity and maximizing FFS revenue will need to give way to an emphasis on proactively managing comprehensive care and wellness, both physical and behavioral.” That means that, in addition to CCM and PCM, providers should also leverage the new codes for AWV (Annual Wellness Visits), TCM (Transitional Care Management), and BHI (Behavioral Health Integration). The article outlines the significant benefit for both providers and their patients.

  • Identifies at-risk patients without the need for a full-on exam by the physician
  • Improves utilization and patient health
  • Decreases both admissions and readmissions
  • Enhances triage and referrals while reducing gaps in care
  • Enables ongoing care management outside the exam room
  • Allows for more integrative care between specialties and other providers

Early data show that, in general, CCM services are increasing patient and practitioner satisfaction, saving cost and enabling solo practitioners to remain in independent practice

Medicare Replacement Value

Many providers have existing relationships with a Medicare replacement plan. While the incentives can vary from plan to plan, the new managed care services present a significant opportunity. For example, the CMS and United will pay an extra $150 per patient for AWV. That can really add up and, again, without the need for a complete exam. All that is required is filling out the paperwork.  


It is estimated that more than 117 million adults in the US are living with one or more chronic health conditions, and 25% have two or more. According to the Centers for Disease Control and Prevention, 90% of the $3.5 trillion in annual healthcare spending is attributable to chronic conditions. And it’s expected to get worse as the nation ages as older patients are likely to have more chronic illnesses. As such, there is an escalating need to address this chronically ill population to reduce hospitalizations, readmissions, lengths of stay, and costs, while improving patient satisfaction.

Even as providers push back, there is no disagreeing that the need for change is urgent. Fortunately, there is a way to help improve the health of our populations and achieve significant revenue benefits without the steep investment in technology or resources. In our next blog, we’ll discuss the option of partnering with a chronic care management company, what to look for, what to avoid, and how to get the most from that investment.

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