CMS Proposes Payment to Physicians to Train Caregivers

Article Highlights

• What are Caregiving Training Services (CTS)?
• What is the definition of a caregiver?
• Which patients benefit from Caregiving Service Training?
• What are the criteria for receiving payment as a caregiver?

For CY 2024, CMS is paying physicians for Caregiving Training Services. CMS payments may be made for CTS services when the treating practitioner identifies a need to involve and train one or more caregivers to assist the patient in carrying out a patient-centered treatment plan. The CTS services are furnished outside the patient’s presence. The treating practitioner must obtain the patient’s (or representative’s) consent for the caregiver to receive the CTS. We further propose that the identified need for CTS and the patient’s (or representative’s) consent for one or more specific caregivers to receive CTS must be documented in the patient’s medical record.

The Caregiving Training Services must be congruent with the treatment plan and designed to effectuate the desired patient outcomes. CMS believes this is especially the case in medical treatment scenarios where assistance by the caregiver receiving the CTS is necessary to ensure a successful treatment outcome for the patient – for example, when the patient cannot follow through with the treatment plan for themselves (see examples in the section under “Which Patients Benefit from Care Involving Caregivers”).

How is a “Caregiver” Defined?

CMS broadly defines a caregiver as a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition. CMS believes 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.

CMS includes a guardian in this definition when warranted. For CTS, “caregiver” also refers to guardians, who for purposes of CTS, are the caregiver for minor children or other individuals who are not legally independent. In these circumstances, a caregiver is a layperson assisting the patient in carrying out a treatment plan that is established for the patient by the treating physician or practitioner and assists the patient with aspects of their care, including interventions or other activities related to a treatment plan established for the patient to address a diagnosed illness or injury. The treating practitioner would train caregivers in strategies and specific activities that improve symptoms, functioning, and adherence to treatment related to the patient’s primary clinical diagnoses. Caregiver understanding and competence in assisting and implementing these interventions and activities from the treating practitioner is critical for patients with functional limitations resulting from various conditions.

Which Patients Benefit from Care Involving Caregivers?

CMS believes that a patient-centered treatment plan should appropriately account for clinical circumstances where the treating practitioner believes the involvement of a caregiver is necessary to ensure a successful outcome for the patient and where, as appropriate, the patient agrees to caregiver involvement.

There may be clinical circumstances when it might be appropriate for the physician or practitioner to directly involve the caregiver in developing and carrying out a treatment plan. Such clinical circumstances could include various physical and behavioral health conditions and circumstances under which CTS may be reasonable and necessary to train a caregiver who assists in carrying out a treatment plan. Conditions include but are not limited to stroke, traumatic brain injury, 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.

Another example, patients with dementia, autism spectrum disorder, or individuals with other intellectual or cognitive disabilities may require assistance with challenging behaviors in order to carry out a treatment plan, patients with mobility issues may need help with safe transfers in the home to avoid post-operative complications, patients with persistent delirium may require guidance with medication management, patients with certain degenerative conditions or those recovering from stroke may need assistance with feeding or swallowing.

How the Caregiver Payment Will Work

Separate from medical circumstances, CMS seeks to avoid potentially duplicative payment. They would not expect the caregiver population receiving these services on behalf of the patient to also receive CTS on behalf of the patient under another Medicare benefit category or Federal program.

When Medicare and Medicaid cover the same services for patients eligible for both programs, Medicare generally is the primary payer in accordance with section 1902(a)(25) of the Act. Based on the specificity of the coding, CMS does not expect that CTS will neatly overlap with any other coverage for patients who are dually eligible for Medicare and Medicaid.

CPT Codes Associated with Caregiver Training Services

In the code descriptors, (CPT codes 96202 and 96203 (caregiver behavior management/modification training services) and CPT codes 9X015, 9X016, and 9X017 (caregiver training services under a therapy plan of care established by a PT, OT, SLP), treating practitioners may train caregivers in a group setting with other caregivers who are involved in care for patients with similar needs for assistance to carry out a treatment plan. Training for all the caregivers for the patient could occur simultaneously, and the applicable CTS codes (CPT code 96202, 96203, and 9X017) would be billed once per beneficiary. CMS proposes to require the full 60 minutes of time to be performed to report CPT code 96202. The add on code, CPT code 96203, may be reported once 75 minutes of total time is performed. billed considering the established treatment plan involving caregivers for the typical patient.