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.

• https://www.federalregister.gov/public-inspection/2023-24184/medicare-and-medicaid-programs-calendar-year-2024-payment-policies-under-the-physician-fee-schedule
• MLN Matters article Jan. 2024
• https://www.cms.gov/files/document/mln9201074-health-equity-services-2024-physician-fee-schedule-final-rule.pdf-0
• These are not on the telehealth list; they are in person services

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.

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.