This is information from the 2024 Physician Fee Schedule PROPOSED Rule
CMS is proposing to recognize and pay for two existing, currently bundled CPT® codes and three new CPT® codes that will allow physicians and other qualified health care professionals to provide training for caregivers of patients.
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. These existing codes had a status indicator of bundled and CMS is proposing to change that to active in 2024.
The other three codes are new for 2024. The codes in this article and the Proposed Rule are placeholder codes until CPT® releases the 2024 code set. Two of the codes, 9X015 and 9X016 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, 9X017 is for group training of multiple sets of caregivers (who are caring for different patients). That group training code is not assigned a time.
|96202||Bundled||Active||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||Bundled||Active||each additional 15 minutes||Behavior management/ modification training||Multiple sets of caregivers (regarding different patients)||Entire 15 minutes|
|9X015*||N/A||Active||(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|
|9X016*||N/A||Active||each additional 15 minutes||Functional performance of ADLs||One or more caregiver (s) for a single patient||Entire 15 minutes|
|9X017*||N/A||Active||(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|
* Placeholder code until CPT releases the 2024 code set
CMS Definition of a caregiver
CMS has defined a caregiver as a layperson who assists in the care of the patient.
“In our ongoing education and outreach work on the use of caregivers in assisting patients, we have broadly defined a caregiver as a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition. Further, in the context of our proposals for CTS services, we believe a caregiver is an individual who is assisting or acting as a proxy for a patient with an illness or condition of short or long- term duration (not necessarily chronic or disabling); involved on an episodic, daily, or occasional basis in managing a patient’s complex health care and assistive technology activities at home; and helping to navigate the patient’s transitions between care settings. For purposes of CTS, we also are including a guardian in this definition when warranted. For CTS, when we say “caregiver” we are also referring to guardians who for purposes of CTS, are the caregiver for minor children or other individuals who are not legally independent.” p. 222-223.
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. 223-224. Patients may require assistance with “challenging behaviors in order to carry out a treatment plan” or with safe transfers, feeding or swallowing.
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. Each behavior should be clearly identified and documented in the treatment plan, and the caregiver should be trained in positive behavior management strategies.” p. 228
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 9X017, and these codes would be billed once per beneficiary.
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