In an exciting turn of events, the Centers for Medicaid and Medicare Services (CMS) have released a draft of the Physician Fee Schedule for 2023 for public comment—and it is clear that the collective efforts of AACIPM and its member organizations on the 2022 PFS have been highly influential in the development of the 2023 PFS!
What did CMS say in direct response to AACIPM’s 2022 recommendations?
Having received over 1,900 public comments related to potential separate coding for chronic pain management in 2022, CMS delayed making related changes but promised to “carefully consider this feedback for future rulemaking.” The efforts of AACIPM’s stakeholders did not go unnoticed, as recommendations #2 and #4 from our letter were directly quoted by CMS in their summary of public comments, as they wrote: “One commenter recommended that “CMS establish a multi-stakeholder working group to determine operational details and resource allocation” and requested that CMS “establish a pilot program using innovative payment methodologies.””
Further, in the Section 6032 Report and Action Plan, CMS included a recommendation to explore the possibility of establishing a new bundled payment under the Medicare Physician Fee Schedule for integrated multimodal pain care that could include certain elements such as diagnosis, a person-centered plan of care, care coordination, medication management, and other aspects of pain care.
How is CMS directly responding to AACIPM in 2023?
Clearly referring to the AACIPM letter, CMS wrote: “One commenter stated that beneficiaries with complex chronic pain conditions may require a lot of time for correct dosing of medications and counseling, and that such time is not captured effectively using existing E/M codes. This commenter also believed that separate coding and payment for chronic pain management could help with better understanding of the treatment of chronic pain than when the service is reported with existing visit codes and would allow for valuation based on the resources involved in furnishing these specific services to people with chronic pain, enhancing the likelihood of appropriate payment, especially for non-face-to-face time involved with the service.”
CMS went on to express direct agreement with the position and arguments found within the AACIPM letter by stating: “We also expect that creating separate coding and payment for CPM will help facilitate the development of data regarding the prevalence and impact of chronic pain in the Medicare population, where conditions including osteoarthritis, cancer, and other similar conditions that cause pain over extended periods of time are common. Such information can assist us in identifying potential coding and valuation refinements to ensure appropriate payment for these services. We also believe that the comprehensive care management involved in CPM services may potentially prevent or reduce the need for acute services, such as those due to falls and emergency department care associated with chronic pain, and also have the potential to reduce the need for treatment for concurrent behavioral health disorders, including substance use disorders. There is some evidence that addressing chronic pain early in its course may result in averting the development of “high-impact” chronic pain in some individuals…”
Last year, in response to the proposed 2022 PFS, AACIPM had issued recommendations related to the creation of standalone pain codes, both time-based and value-based, and the need for CMS to ensure that a wide-range of clinicians and community-based services are able to provide guideline-concordant integrative pain care. We urged CMS to create a standalone code that would support the use of team-based care through bundled payments, explaining that such a code would better enable CMS to determine quality, measurement, and outcomes. for future rulemaking, and did directly quote some of the recommendations from the AACIPM letter.
Upon the release of the draft version of the 2023 Physician Fee Schedule, we were happy to see that CMS is now proposing to implement many of the recommendations that had been submitted by AACIPM in 2022. What’s more, CMS again extensively quoted AACIPM’s letter as they presented the changes they intend to make in 2023 and the arguments in support of those changes.
CMS is now proposing two new HCPCS codes for chronic pain management and treatment services:
- HCPCS code GYYY1: Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care (e.g. physical therapy and occupational therapy, and community-based care), as appropriate. Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (When using GYYY1, 30 minutes must be met or exceeded.)
- HCPCS code GYYY2: Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month (List separately in addition to code for GYYY1). (When using GYYY2, 15 minutes must be met or exceeded.)
CMS is accepting public comments through September 6th and has expressed a significant interest in receiving additional feedback on these codes, and the definitions which will apply to them, asking the public for input on a great deal of topics, including:
- Definition of “chronic pain” for purposes of these codes
- How to document the nature of a person’s pain in the medical record.
- The proposed inclusion of “administration of a validated pain assessment rating scale or tool” as an element of the proposed CPM services, and on whether a repository or list of such tools would be helpful to practitioners delivering CPM services.
- The appropriateness of the proposed 30-minute duration per calendar month for GYYY1, and also on the proposed duration and frequency for GYYY2, and whether we should consider specifying a longer duration of time for GYYY1 or GYYY2.
- How best the initial visit and subsequent visits should be conducted (for example, in-person, via telehealth, or the use of a telecommunications system, and any implications for additional or different coding).
- Comments on the care coordination that may occur between relevant practitioners furnishing services, such as complementary and integrative care, and on the community-based care element included in the descriptors for proposed GYYY1 and GYYY2.
- Which, if any, CPM elements could be furnished as “incident to” services, and whether to add GYYY1 and GYYY2 to the list of services fo which general supervision is allowed.
- What elements of the CPM services could be furnished under general supervision, or direct supervision.
- How to value these services (valuation information starts on page 229 of the draft PFS.)
- Whether to add the CPM codes to the Medicare Telehealth Services List.
- Whether CMS should consider creating additional coding and payment to address acute pain.
While AACIPM is extraordinarily pleased to see CMS taking this step, it is imperative that we once again weigh on in these important new codes to ensure they make it across the finish line. In the coming weeks, our alliance will soon be meeting to discuss CMS’ proposal in detail, working to identify any provisions that should be amended prior to finalization and working to help answer the questions that CMS has asked, above. All public comments must be submitted no later than September 6, 2022.
To all of you that have worked so hard on these efforts, thank you, congratulations, and we can’t wait to work with you to see these new codes finalized!
If you represent an organization that would like to aid in this effort, please contact Amy@PainManagementAlliance.org.
Related Article:
AACIPM Issues Recommendations on Comprehensive Pain Management Under Medicare (Sept. 2022)