APA Hails Collaborative Care Codes, Urges CMS to Reconsider Payment Plan

APA has strongly commended the Centers for Medicare and Medicaid Services (CMS) for proposing coverage for collaborative care services beginning in January 2017, calling the government’s recognition of collaborative care—and the role of psychiatrists in that model—“a huge advancement in health policy.”

“For patients with common behavioral disorders who are treated in primary care, the collaborative care model (CoCM) maximizes the effectiveness of current behavioral health treatments by ensuring that patients are identified, treated, and monitored proactively, with clinical guidance provided by a qualified psychiatric consultant,” wrote APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a letter last month to CMS Administrator Andrew Slavitt, M.B.A. “In this model, primary care providers receive extensive support from a team that includes a trained behavioral health care manager and a psychiatric consultant. Patients benefit from the heightened benefits of a collaborative, team-based approach that applies well-established principles of population-based behavioral health care and employs specific behavioral health expertise.”

The letter was in response to the proposed Medicare Physician Fee Schedule issued in July (Psychiatric News, August 5) and includes extensive recommendations for refining or revising the proposed rule. The comments include detailed recommendations for a host of proposals in the rule, but focus especially on the new codes for coverage of collaborative care services that can be submitted by primary care physicians (GPPP1, GPPP2, GPPP3). The final rule is expected to be issued around November 1.

(G codes are temporary codes, and they had to be used for the 2017 collaborative care codes because they will not be finalized in time to be incorporated into the 2017 CPT manual.)

In the proposed rule, published in the Federal Register on July 15, CMS proposed to support payment of psychiatrists for consultative services they provide to primary care physicians in the CoCM, citing models of collaborative care described or reviewed in publications from the University of Washington, the Institute for Clinical and Economic Review, and the Cochrane Collaboration. The codes themselves are submitted by the primary care physician.

While hailing the three new codes for these services, APA also urged CMS to reconsider the proposed payment amount. APA noted that the proposed work values for the codes underestimate the work involved and are not sufficient to sustain the model.

“We believe that the proposed valuation of the psychiatric consultant is not representative of the actual work being performed,” Levin wrote. “CMS’s proposal to crosswalk the work of the psychiatric consultant [in the three codes] to CPT code 90836, Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service, for a work RVU of 0.42, is not appropriate. … While psychotherapy is an important management option, it is not the work being performed. The psychiatric consultant’s work is inherently medical and is more equivalent to the medical decision making of an evaluation and management (E/M) service.”

Levin noted that patients enrolled in the CoCM are typically those who have not responded to standard care and need additional specialty evaluation and involvement to enable the development of an appropriate and effective treatment plan. The psychiatrist is evaluating the patient’s condition based upon the data provided by the primary care provider and the behavioral health care manager including medical history, prior treatment history, and other pertinent biopsychosocial information.

“In sum, the proposed crosswalk is based upon a misunderstanding of the work of the psychiatric consultant and would result in values insufficient to sustain the model, which would also impede adoption of the CoCM,” Levin wrote. “The work of the psychiatric consultant in all three codes should be valued no less than that of the primary care physician.”

In the proposed rule, CMS also supported payment for another new code—GPPPX—to pay for “care management services for behavioral health conditions” in primary care settings. In its letter, APA generally supported adoption of the new code but sought clarification from the administration.

“We commend CMS’s effort to expand Medicare coverage and payment to additional services involving care for patients with behavioral health conditions based on the recognition that significant time and resources are expended on patients with behavioral health conditions that are not currently compensated,” Levin wrote.

“However, it is not clear from the proposed rule precisely which services, practitioners, patients, and circumstances would qualify for the billing of the GPPPX code. We recommend that CMS provide further clarification regarding the precise services contemplated for g-code GPPPX.”

APA’s letter also includes detailed responses to the CMS proposal to provide payment for “prolonged services codes” for time spent providing non-face-to-face services following an E/M visit and coverage for assessment and care for cognitive impairment. ■