Managing the Care of Patients
This month’s newsletter will again feature a foundational piece of value-based care with an innovation closely tied to it. Both involve ways of managing the care of patients and providing the needed support to improve outcomes.
Principal Care Management (PCM) has been around for 4 years, and it can ride on a very similar chassis to programs like Chronic Care Management (CCM) and Transitional Care Management (TCM). This is what makes it foundational. Principal Illness Navigation, on the other hand, didn’t go live until January 2024, so it’s still a cutting-edge tool in the toolbox.
In the world of healthcare, there are so many potential programs and processes that can be deployed, and some (most) of them have been around a long time. Knowing about their existence and how to use them has been a challenge for practices and organizations.
Implementing new things into your practice has at least two steps before you start writing your P&P Manual.
Know your patient population and their needs. Awareness of the prevalent issues – medical, behavioral, social, etc. – guides you in knowing what issues need to be addressed and in what priority. What resources will you need to access, build, or buy to focus on them? Once you understand the needs of your population you can …
Find programs, revenue models, billing codes (where applicable), and examples of how others have addressed the issues you face. You need a trusted resource for all things CMS, Medicaid in your state, and commercial payers. This is also where it’s advantageous for those of us in healthcare to open up our cupboards and let others see our ketchup and the ingredients we use in our special sauce.
Good patient care is not a zero-sum game. There’s no trophy or ribbon for the best sauce. There’s enough work for everyone out there willing to throw your heart and shoulder into it to improve outcomes. We need to keep looking for opportunities to improve and share them with our colleagues.
Tried & True
Most folks in primary care medicine are very familiar with the Chronic Care Management (CCM) and Transitional Care Management (TCM) programs. CMS created these care models for patient intervention in 2015 and 2008 respectively, and since then, practices and organizations have been using these opportunities to manage patients’ care and have billable codes to create revenue for their efforts. Those engaged in VBC have also used these as tools to try to lower medical expense through improved outcomes.
In 2020, CMS created another means of patient care management, Principal Care Management (PCM). This has yet to get the attention of practices to the extent its TCM and CCM predecessors have, but it’s impact can be the same. Some have relegated PCM to be “only for the specialists,” but I don’t think that’s the case.
PCM is a model of care that reimburses providers for coordinating clinical care with patients who have one complex chronic or serious BH/MH condition, lasting 3 or more months. This condition must have led the patient to have had either a recent hospitalization, an acute risk of death or exacerbation (including hospitalization), an acute risk of functional decline (including a planned or possible need for SNF), or be a case that requires management that’s “unusually complex due to comorbidities.” (For non-clinical care coordination, see the PIN article below.)
There is some overlap of PCM with TCM and CCM services, but major differences include:
CCM requires at least 2 chronic conditions, rather than just one.
PCM requires instability (or at least the potential of it) whereas CCM does not.
TCM only applies when there’s been a discharge from inpatient admission and lasts only 30 days.
The place where two of these models are used with the same patient is most often after an acute care admission. PCM is frequently billed as part of a continuum with TCM after the 30-day mark.
Conditions where PCM is commonly appropriate include cancer treatment, HIV, Dementia, COPD, HF, severe mental illness (SMI), and substance use disorder (SUD).
The care team is expected to create, monitor, and revise a disease-specific care plan for the individual patient, making any necessary adjustments along the way. Those ongoing changes are expected within the model construct and are built into the reimbursement guidelines — e.g., qualifying conditions are defined as requiring “frequent adjustments in the medication regimen” and/or needing “ongoing communication and care coordination between relevant practitioners furnishing care.”
Therefore, keeping a close eye on a patient and their condition is essential. This can be through direct human contact, bidirectional SMS messaging, remote patient monitoring, and other modalities outside the walls of the practice.
PCM services include the clinical piece of tasks like:
Health system navigation – referrals to specialists, facilities, or healthcare providers
Person-centered planning, including a disease-specific care plan
Practitioner, consultant, provider/facility-based care coordination or communication
Adjustments of the plan and treatment as needed
From a practical, revenue perspective:
PCM CPT® codes, 99424, 99425 – service provided personally by physician or other qualified health care provider every month. 1st and subsequent 30 minutes.
99426 and 99427 - clinical staff time directed by physician or other qualified health care professional, per calendar month, where services provided are directly supervised (physician or other qualified health care provider is immediately available). 1st and subsequent 30 minutes.
Much of the infrastructure built for the CCM and TCM work that you’re already doing can be used for PCM, and your patient reach and impact can expand. Chances are, you and your staff are already spending the time with these “single condition” patients, so bill for it. This will both help pay for the services rendered and justify the work you’re doing to decrease overall medical expense in your VBC contracts. Oh, and it helps the patients, too. 😉
Innovation
A recent development in care management billable services is Principal Illness Navigation (PIN), started by CMS in January 2024. This is an offshoot of Principal Care Management (PCM), intended to help address health equity issues by covering the costs of non-clinical care coordination in people with a serious, volatile medical or mental health condition.
Generally, PCM is used for care coordination of clinical needs that are outside the four walls of a physician’s office, whereas PIN is designed more to address the Social Drivers of Health (SDOH) and non-clinical barriers to care that can occur with certain conditions.
Like PCM, PIN covers coordinating care for patients who have one serious, high-risk condition, expected to last 3 or more months. The patient must be at risk for at least one of the following:
Hospitalization
Death
Condition exacerbation (including hospitalization)
Functional decline (physical or mental, including a planned or possible need for SNF).
The chosen condition requires development, monitoring, or revision of a disease-specific care plan, and may require frequent adjustment in the medication or treatment regimen, repeated communication with community-based resources, or substantial assistance from or to a caregiver.
PIN-appropriate conditions are like those for PCM and include cancer treatment, HIV, Dementia, COPD, HF, severe mental illness (SMI), and substance use disorder (SUD). Provision of PIN services aims to identify non-clinical needs and connect the patient with appropriate support resources.
It takes time and intention to identify and address these issues, especially when done the most effective way, with closed-loop referrals. Closing the loop is where many practices fall short, but that’s the piece needed to ensure the patient is getting the services they need.
The services for PIN are performed by “auxiliary personnel” and billed “incident to” the physician or provider, all after an initiating visit where the need is identified as medically necessary. This initiating visit can be a 99213-5 visit, an Annual Wellness Visit, a Psychiatric diagnostic evaluation (such as 90791), or Health Behavior Assessment and Intervention services (like 96156). The clinician billing the initiating visit will bill subsequent services as “incident to.”
The auxiliary personnel role is typically filled by a Community Health Worker (CHW), a Navigator, or a Peer Support person, and their services can be rendered face-to-face or virtually. Their services can only be billed in a non-facility setting. Remember: outside the walls and halls.
These team members can be employees, leased employees, or independent contractors of the billing practitioner. They can’t have been excluded from the Medicare, Medicaid, or other federally funded health care programs by the Office of the Inspector General or had their Medicare enrollment revoked. Additionally, they must meet any applicable requirements to furnish “incident to” services, including licensure, imposed by the State in which the services are being furnished.
In States with no applicable licensing requirements, Navigators and CHWs providing PIN services must be trained or certified in the competencies of:
Patient and family communication
Interpersonal and relationship-building
Patient and family capacity building
Service coordination and systems navigation
Patient advocacy, facilitation, individual and community assessment
Professionalism and ethical conduct
Development of an appropriate knowledge base, including specific certification or training on the serious, high-risk condition, illness, or disease being addressed.
As noted, the PIN model also allows for a Peer Support person (PIN-PS) to better sustain and guide patients with a serious, high-risk mental health condition, especially substance use disorder. Peer Support team members must also meet applicable State requirements, including certification or licensure. In States with no applicable requirements, PIN-PS service providers must receive training consistent with the National Model Standards for Peer Support Certification published by the Substance Abuse Mental Health Services Administration (SAMHSA).
PIN and PIN-PS services include items like:
Health system navigation, especially for the social barriers obstructing care provision
Person-centered planning
Identifying or referring patient and caregiver or family, if applicable, to supportive services
Practitioner, home, and community-based care coordination or communication
Patient self-advocacy promotion and understanding of their condition
Community-based resources access facilitation
The services for PIN and PIN-PS are billed using HCPCS codes. When provided by trained patient navigators or CHWs, codes G0023 and G0024 (additional 30 minutes) can be used. For the PIN-PS time, use G0140 and G0146 (additional 30 minutes).
Effective and successful healthcare delivery in the VBC space depends on addressing the whole person – medical conditions, mental health issues, and social influences on their lives – especially outside the confines of the doctor’s office. PIN gives a reimbursable avenue to address those issues in certain high-need patients.
Doing so for them can bring in some revenue for a practice, but more importantly it gets the practice thinking in whole person terms, it builds relationships with resources in the community that can help all your patients, and it facilitates the construction of infrastructure to address social risks and obstacles to care in your entire patient population.
The BoPC team is attending Rise's Value-Based Summit on June 3rd and 4th in Atlanta, GA. Interested in joining us? Our readers can use the 15% off promo code RISEVBC at https://vbc.risehealth.org/