CMS Creates New Pain Management Codes Heeding Advice of AACIPM

The Centers for Medicare & Medicaid Services (CMS) has issued its finalized 2023 Physician Fee Schedule, creating, for the first time, billing codes at the federal level that are specific to the delivery of chronic pain management (CPM) services. These codes (HCPCS G3002 and G3003) pertain to chronic pain lasting longer than three months, may be billed by a physician or other qualified health practitioner, and cover services including:

• administration of a validated pain rating scale or tool;
• the development, implementation, revision, and/or 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;
• facilitation and coordination of any necessary behavioral health treatment;
• pain and health literacy counseling;
• any necessary chronic pain-related crisis care; and/or,
• ongoing communication and care coordination between relevant practitioners furnishing care (e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care), as appropriate.

In September 2022, AACIPM issued comments in response to CMS’ proposed codes for CPM services, along with signatories representing patient organizations, large scale health systems, employer purchasers of healthcare, private insurers, pain management clinicians and educators, and other experts in the field of comprehensive and integrative pain management. The collective comments were offered to CMS in the hopes of helping the agency achieve its goals of: (1) encouraging the adoption of high-quality integrative pain care while minimizing reliance on higher risk, low value care that is often more costly, (2) collecting accurate data on the number of people requiring treatment for chronic pain and the types of services they require, and (3) promoting health equity.

We are pleased to announce that, not only did CMS adopt the new CPM codes, but nearly all of the recommendations issued by AACIPM were substantially addressed within the final release. AACIPM is incredibly grateful for the extensive participation of our stakeholders throughout the development of these CPM codes, as it is only through the strength of our collective voice that we have been so incredibly impactful in helping to design the newly adopted codes.

AACIPM asked CMS to clarify the codes to ensure that clinicians are not responsible for providing every listed service, allowing for flexibility in individual treatment plans based on the patient’s needs and the geographically available services. In the final release, CMS specifically states, “We are clarifying that clinicians will be required to furnish all appropriate elements of the code bundle, but also clarifying that we do not expect that all elements of the code bundle will be appropriate for every patient.”

AACIPM asked CMS to clarify and/or redraft the CPM codes so that only the initial CPM visit is required to be in-person, and that follow-up CPM visits may be delivered in-person or remotely, whether or not they occur within the same month. CMS has agreed that certain elements of the proposed codes, such as care planning or care coordination with other health care professionals, would not likely require face-to-face care. While CMS will be requiring an initial face-to-face visit in order for the CPM codes to be billable, they will not be requiring in-person care for each subsequent visit, whether these be monthly or at some other time.

AACIPM asked CMS to allow providers to bill for CPM codes on the same day that a patient is being seen for a general visit or for another illness or condition. While the original proposal would have disallowed such billing, the final release heeds the advice of AACIPM. CMS states: “Many Medicare beneficiaries have multiple chronic conditions, and many of these conditions could involve chronic pain. We believe it is reasonable to assume that in many instances, the clinician could be spending time with the Medicare patient discussing health and wellness related to a variety of conditions that person may be experiencing, or expect to experience, and that interaction might not have a focus on the chronic pain aspects of the person’s care. Additionally, if the person with pain has made the effort – which could be considerable, as commenters have noted, to get to an appointment with a clinician, it makes sense from a burden standpoint – allowing for the burden on both the clinician, and the person with Medicare, to permit billing for both the E/M service, and the CPM service(s) on the same day. Therefore, if all requirements to report each service are met, without time or effort being counted more than once, then both E/M and CPM may be billed on the same day.”

AACIPM expressed significant concern at the proposed requirement to require “administration of a validated pain rating scale or tool” and at the suggestion that a specific tool be required, citing concerns with pain bias, proprietary systems, and established outcomes beyond such scales. While CMS will be requiring that billing providers utilize a validated pain scale, it will not be requiring the use of any single pain assessment measure, “because no particular tool or tool set can assess the complex nature of the experience of pain across all individuals, nor appropriately guide its treatment.” Further, heeding AACIPM’s advice to further investigate these tools, CMS is working with NIH to create and disseminate an accessible, curated, and dynamic set of Pain Assessment resources for clinicians seeking instruments to assess their patients’ pain and pain-related symptoms.

AACIPM expressed significant concern with the rate of compensation being proposed in conjunction with the CPM codes. While CMS is going forward with their initial proposal to crosswalk G3002 and G3003 to CPT codes 99424 and 99425, respectively, CMS has also stated that it will be utilizing the data collected from the use of these CPM codes to further hone the correct payment as time goes on, as it “…is not our intent to either underpay, or create incentives for clinicians to use other codes that would constrain the use of the new codes.”

AACIPM requested that CMS remove any mention of “bundles” or “bundling” from the CPM codes to eliminate confusion with traditional bundles based on outcome measures. CMS has apologized for any confusion by its use of the word “bundle” and has removed all mentions of the word from the finalized codes, clarifying that by “bundle” the agency was merely referring to all of the elements contained within the CPM code descriptors.

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