This is information from the 2024 Physician Fee Schedule Final Rule, published Nov. 2, 2023. You can read it for yourself by downloading the pdf below.

• 2024 Physician Fee Schedule Final Rule, published Nov. 2, 2023
• MLN Matters article Jan. 2024 – PDF
  • These are not on the telehealth list; they are in person services
• Caregiver Training Services, Behavior Management/Modification | G0539, G0540
• Caregiver Training Services, Direct Care Strategies | G0541, G0542, G0543

CMS will recognize and pay for two existing CPT® codes, which in 2023 had a status indicator of bundled (96202 and 96203), and three new CPT® codes that will allow physicians and other qualified health care professionals to provide training for caregivers of patients (97550-97552)

One set of codes (96202, 96203) is for group training in behavior management/modification of patients with a mental or physical health diagnosis. The group training would include caregivers of different patients. More than one caregiver/patient can be in the training.

Two of the new codes, 97550 and 97551 are for caregivers of an individual patient to facilitate the patient’s functional performance in their home and community relating to Activities of Daily Living. (ADL) These are timed codes, 30 minutes and 15 minutes respectively. The third new code, 97552 is for group training of multiple sets of caregivers (who are caring for different patients). That group training code is not assigned a time. More than one caregiver trained at the same session must be billed under the group code, as the treating practitioner’s time should not be counted multiple times.

Code	Definition	Service	Participants	Time
96202	Multiple-family group behavior management/ modification training for parent(s)/guardian(s)/ caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/ caregiver(s); initial 60 minutes	Behavior management/ modification training	Multiple sets of caregivers (regarding different patients)	Entire 60 minutes
96203	each additional 15 minutes	Behavior management/ modification training	Multiple sets of caregivers (regarding different patients)	Entire 15 minutes
97550	(Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face; initial 30 minutes),	Functional performance of ADLs	One or more caregiver (s) for a single patient	Entire 30 minutes
97551	each additional 15 minutes	Functional performance of ADLs	One or more caregiver (s) for a single patient	Entire 15 minutes
97552	(Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers).	Functional performance of ADLs	Multiple sets of caregivers (regarding different patients)	Not timed

 

CMS Definition of a caregiver

CMS adopted a definition of  caregiver after reviewing comments sent in after they released their proposals.

After considering the public comments, we are finalizing a revised definition of caregiver to be “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation” and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition”.  p. 294 of the Final Rule

Examples of health conditions

CMS states that conditions include, but are not limited to “stroke, traumatic brain injury (TBI), various forms of dementia, autism spectrum disorders, individuals with other intellectual or cognitive disabilities, physical mobility limitations, or necessary use of assisted devices or mobility aids.” p. 295. Patients may require assistance with “challenging behaviors in order to carry out a treatment plan” or with safe transfers, feeding or swallowing. They state this list of examples is not exhaustive.

The services must be “reasonable and necessary.” CMS is also expressing concern that they could be duplicative of other training that a caregiver has received, and they want to avoid duplicate payments. The training should be directly relevant to the person-centered treatment plan for the patient in order for the services to be considered reasonable and necessary under the Medicare program. The patient is not present for the training so that the practitioner and caregiver attention is solely focused on the training.

Each behavior should be clearly identified and documented in the treatment plan, and the caregiver should be trained in positive behavior management strategies. In terms of frequency, they say,

“In other words, the medical necessity of CTS for the patient should determine the volume and frequency of the training.” p. 297.

There may be instances in which the patient has a new caregiver who needs the training. The volume and frequency for the same patient may be based on the treatment plan, changes in the patient’s condition, the diagnosis or the caregivers.

CMS says that although caregivers of different patients can be trained together, training for all caregivers for the patient could occur simultaneously for codes 96202, 96203 and 97552, and these codes would be billed once per beneficiary. These codes are for multiple-family groups of patients with similar conditions.

Caregivers are taught how to structure the patient’s environment, reinforce desired behaviors, to reduce the negative impact of the patient’s diagnosis on their daily live, and to develop structure technical skills to manage the patient’s challenging behavior.

Professionals who will report the service

The CPT codes 96202 and 96203 are defined as services provided by a physician or other qualified health care professional.

“As with other established coding, we expect that the treating practitioner who furnishes and bills for CTS to furnish services as described by the codes.” p. 290.

CMS states that codes 97550, 97551 and 97552 are

“caregiver training services under a therapy plan of care established by a PT, OT, SLP.” p. 288.

These last three codes will be considered “sometimes therapies.” The focus of these caregiver training services is to facilitate “the patient’s activities of daily living, transfers, mobility, communication, and problem-solving to reduce the negative impacts of the patient’s diagnosis on the patient’s daily live and assist the patient in carrying out a treatment plan.” p. 301

The caregiver is trained in skills to assist the patient in completing ADL tasks.

Consent from the patient or their representative is required, and CMS emphasized this is especially important because these are services that are performed without the patient present.

CMS is not proposing to add these to the telehealth list.

Caregiver Training Services, Behavior Management/Modification

HCPCS codes: G0539, G0540

Descriptor:

• G0539 (Caregiver training in behavior management/modification for caregiver[s] of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional [without the patient present], face-to-face; initial 30 minutes)
• G0540 ( … ; each additional 15 minutes)

2025 fees: G0539 ($52.08), G0540 ($25.55)

Key details: In ways similar to the 2023-effective behavior management/modification caregiver training codes 96202 and 96203 for group training, the newly proposed caregiver training services (CTS) codes G0539 and G0540 are instead oriented toward individual training, “furnished to the caregiver(s) of an individual patient,” according to CMS. “Behavior management/modification training for caregivers of Medicare beneficiaries should be directly relevant to the person-centered treatment plan for the patient in order for the services to be considered reasonable and necessary under the Medicare program,” CMS states. Patient consent is required and can be provided verbally by the patient.

Caregiver Training Services, Direct Care Strategies

HCPCS codes: G0541, G0542, G0543

Descriptor:

• G0541 (Caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications [including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control] [without the patient present], face-to-face; initial 30 minutes)
• G0542 ( … ; each additional 15 minutes [List separately in addition to code for primary service])
• G0543 (Group caregiver training in direct care strategies and techniques to support care for patients with an ongoing condition or illness and to reduce complications [including, but not limited to, techniques to prevent decubitus ulcer formation, wound care, and infection control] [without the patient present], face-to-face with multiple sets of caregivers).

2025 fees: G0541 ($52.08), G0542 ($25.55), G0543 ($22.00)

Key details: As opposed to the behavior management and functional performance improvement codes that CMS activated in 2024, a new series of HCPCS codes would focus on “direct care services and supports” and would apply to more hands-on care training, such as teaching how to change wound dressings or prevent decubitus ulcer formation. “Each training activity should be clearly identified and documented in the treatment plan,” CMS says.

The agency also clarified in the final rule that patients might be receiving care under other Medicare programs. “Caregiving raining may be appropriate for circumstances where a beneficiary’s caregiver need training, but the patient is under a home health plan of care, receiving at-home therapy, or receiving DME services for unrelated conditions,” the final rule states.

The three codes are designated as “sometimes therapy” services, which facilitates payment for the CTS services under the PFS for outpatient physical therapy, occupational therapy and speech-language pathology services “when personally furnished by PTs and OTs, including those provided by their supervised assistants … as well as the CTS personally furnished by SLPs.”