Making the economic value proposition for pharmacist comprehensive medication management (CMM) in primary care: A conceptual framework

Journal Pre-proof Making the economic value proposition for pharmacist comprehensive medication management (CMM) in primary care: A conceptual framework Kristen Tripicchio, Benjamin Urick, Jon Easter, Sachiko Ozawa PII:

S1551-7411(19)30561-3

DOI:

https://doi.org/10.1016/j.sapharm.2020.01.001

Reference:

RSAP 1426

To appear in:

Research in Social & Administrative Pharmacy

Received Date: 19 August 2019 Revised Date:

15 December 2019

Accepted Date: 1 January 2020

Please cite this article as: Tripicchio K, Urick B, Easter J, Ozawa S, Making the economic value proposition for pharmacist comprehensive medication management (CMM) in primary care: A conceptual framework, Research in Social & Administrative Pharmacy (2020), doi: https:// doi.org/10.1016/j.sapharm.2020.01.001. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.

Kristen Tripicchio: Conceptualization, Methodology, Writing – Original Draft, Visualization Sachiko Ozawa: Methodology, Writing – Review & Editing, Supervision, Validation Jon Easter: Conceptualization, Writing – Review & Editing Benjamin Urick: Validation, Writing – Review & Editing

Making the Economic Value Proposition for Pharmacist Comprehensive Medication Management (CMM) in Primary Care: A Conceptual Framework Kristen Tripicchio, PharmD,a Benjamin Urick, PharmD, PhD,a Jon Easter, RPh,a and Sachiko Ozawa, PhDa,b a

Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA. b Department of Maternal and Child Health, University of North Carolina Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, NC, 27599, USA. Corresponding Author: Kristen Tripicchio, [email protected]

1

ABSTRACT

2

Introduction

3

Comprehensive medication management (CMM) is a patient care process provided by clinical

4

pharmacists in primary care settings that ensures optimal use of medications with timely follow-up.

5

Despite widespread evidence that shows CMM improves clinical and medication-related outcomes,

6

pharmacist-delivered CMM services often fail to be adopted into U.S. primary care settings.

7 8

Objective

9

This study presents a conceptual framework linking outcomes of pharmacist-delivered CMM services in

10

primary care settings to financial benefits for health plans providing coverage of CMM services and

11

primary care practices investing and implementing CMM.

12 13

Methods

14

A critical review of the literature was performed in PubMed and the gray literature to identify financing

15

opportunities that justify the coverage of CMM by third-party health plan administrators or the

16

implementation of CMM by primary care practices. Financing elements that could be impacted by

17

pharmacist-led CMM outcomes, namely higher achievement of medication-related quality measures and

18

reduction of total costs of care, were recorded and utilized to develop the conceptual framework.

19 20

Results

21

The framework suggests that CMM provides economic benefits to both health plans and primary care

22

practices by increasing market competitiveness, direct revenue, and quality bonuses. Health plans may

23

benefit from higher plan quality ratings, lower premiums and plan bids, increased shared savings, and

24

quality bonus payments. Primary care practices may achieve increased negotiating power through

25

accreditation recognition and patient satisfaction, increased revenue through shared savings and fee-for-

26

service reimbursement, and achievement of quality bonus payments.

27 28

Conclusions

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The alignment of economic benefits from CMM advances a strong value proposition for greater adoption

30

of CMM coverage by health plans and implementation in the U.S. primary care system. Through broader

31

CMM implementation, pharmacists can work alongside physicians in advanced care models and play a

32

vital role in shaping the primary care practice transition to value-based care.

33

34

Keywords: Comprehensive Medication Management (CMM); clinical pharmacy; medication

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optimization; pharmacist reimbursement; economic framework; business plan; quality of care

36

INTRODUCTION

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The misuse, underuse, and overuse of medications is one of the largest preventable factors contributing to

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lower health care quality in the United States. While retail prescription drug spending in the U.S. is

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estimated to be $330 billion of the $3.3 trillion in total health expenditures, costs resulting from non-

40

optimized medication therapy have been estimated to exceed $500 billion.1,2 This implies that for every

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dollar spent on medications in the United States, an additional dollar is needed to address inappropriate

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medication use. One solution for reducing unnecessary medication-related spending is comprehensive

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medication management (CMM), a clinical service delivered by pharmacists using an integrated care

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team approach. The CMM patient care process ensures that each patient’s medications are evaluated to

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determine appropriateness, effectiveness, safety, adherence, and accessibility.3 Clinical pharmacists

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performing CMM services develop and implement an individualized medication therapy care plan in

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collaboration with the patient and care team. Regular follow up and monitoring are essential to the CMM

48

process in order to ensure optimal medication use, achieve patient-specific goals of therapy, and deliver

49

quality outcomes.3

50 51

Pharmacist-led CMM has consistently demonstrated positive clinical outcomes, which are most often

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achieved through identification and resolution of medication therapy problems (MTPs). Examples of

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relevant CMM interventions include addition of an indicated medication such as a statin or asthma inhaler

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therapy, dose optimization of anti-diabetic agents, or discontinuing an unsafe or unnecessary medication

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such as agents that cause confusion in elderly patients.4 On average, studies of CMM services have

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identified and resolved 4.5 MTPs per patient, with the most frequent types of MTPs identified as

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requiring additional medication therapy or suboptimal dosing of an existing therapy.5–14 In terms of

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diabetes management, studies have shown that CMM leads to significant reductions in hemoglobin A1c

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compared to control arms with estimated treatment differences ranging from -0.4% to -1.7%.15–19

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Moreover, several studies have demonstrated CMM’s positive impact on all-or-none diabetes composite

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scores that involve achievement of several important treatment goals including smoking cessation, daily

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aspirin use, and meeting targets for A1c, low density lipoprotein (LDL), and blood pressure goals.6–8,16

63 64

These clinical benefits have also resulted in cost savings. Some studies of well-adopted CMM services

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have demonstrated a positive impact on lowering patient total cost of care by decreasing hospitalizations

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and other acute care utilization.9,14 Studies reporting the impact of CMM on total patient cost of care

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report total annual savings ranging from $452 to $3678 per patient.8,9,13,14,17 When implemented

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consistently and appropriately, CMM has demonstrated a positive return on investment as high as $12 for

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every $1 invested in primary care practice settings.14

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Despite widespread evidence that shows CMM improves clinical and medication-related outcomes,

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pharmacist CMM services fail to be widely adopted into U.S. primary care settings.20–23 CMM services

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are often funded through unsustainable means such as temporary grants,12,13,17,24 pilot programs,9 or

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limited fee-for-service billing reimbursements.6,7,10,11 Fortunately, the current healthcare policy landscape

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and value-based directive in the U.S. presents a favorable environment for the economic justification of

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pharmacist CMM services. In the new age of emphasis on value and the partial transfer of risk from

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payers to delivery systems, CMM has the potential to be financially viable.25,26 This study presents a

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theoretical framework to conceptualize how CMM-driven outcomes can financially benefit third-party

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health plans and primary care delivery systems deliberating about whether to reimburse for or implement

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pharmacist CMM services.

80 81

METHODS

82

A critical review of the literature was performed to discern financing opportunities that justify the

83

coverage of CMM by third-party health plan administrators or the implementation of CMM by U.S.

84

primary care practices. The literature review focused on financing elements between U.S. healthcare

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financers (individuals, employers, and government), third-party health plan administrators, and primary

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care delivery systems. Specifically, the scope of the framework was limited to health insurance through

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Medicare, Medicaid, fully or self-insured employers, and state or federally run health insurance

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exchanges as these make up the bulk of health financing in the United States.27–29 Financing of primary

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care practices - including physicians organized into accountable care organizations (ACOs) or patient-

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centered medical homes (PCMHs) - was also evaluated.

91 92

Literature searches were conducted in PubMed and the gray literature through use of key terms and

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synonyms that reflected financing models between each of the chosen stakeholders. Terms used to

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identify financing models included: reimbursement, payment, financing, contract, revenue, business

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model, and remuneration. These financing search terms were combined to discern revenue streams from

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the selected lines of business for health plans (i.e. Medicare Advantage plans, Medicare Part D plans,

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commercial plans, Medicaid managed care, fully-funded insurers) and for primary care practices (i.e. self-

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insured employers, commercial health plan contracts, traditional Medicare, Medicare Advantage, and

99

Medicaid). Titles and/or abstracts were scanned to identify articles that discussed relevant revenue

100

models. For financing elements where more detailed information was available (e.g. Medicare Advantage

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Stars quality bonus payments), secondary searches were performed in the gray literature (i.e. Centers for

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Medicare and Medicaid Services (CMS), Healthcare Effectiveness Data and Information Set (HEDIS),

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PCMH accreditation, and ACO accreditation websites) to understand contract specifics such as relevant

104

quality metrics or risk-adjustment factors. Financing elements that could be impacted by the stated

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paradigm were recorded and utilized to develop a conceptual framework.

106 107

In order to develop the narrative framework, a paradigm was applied that presumes pharmacist CMM

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services result in lower total costs of care through decreased acute care utilization and higher achievement

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of medication-related quality measures. Thus, financing elements that could be positively impacted by

110

either lower total costs of care or higher achievement of quality measures were assumed to contribute to

111

the economic justification for CMM. This paradigm is supported by the literature and continues to be

112

evaluated as the value of clinical pharmacy services gains national attention.30,31 We present the

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framework through two perspectives – from the standpoint of third-party health plans and primary care

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practices.

115 116

RESULTS

117 118

CMM Value Proposition within the U.S. Healthcare System: A Conceptual Framework

119

This framework presents the economic value proposition for CMM in primary care settings (Figure 1).

120

Within the framework are three key categories of stakeholders: 1) healthcare financers (i.e. employers,

121

individuals, and government programs for Medicare and Medicaid), 2) third-party health plan

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administrators (TPAs) that facilitate contracts and health benefits on behalf of financers, and 3) primary

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care practices where CMM services may be delivered. In general, payers receive financing from

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healthcare financers (yellow dotted and blue arrows in Figure 1), and then go on to pay primary care

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practices for rendered services (green dashed arrows in Figure 1). Primary care practices may also receive

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reimbursement directly from certain healthcare financers, including traditional Medicare, non-managed

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Medicaid, and self-insured employers (green dashed arrows in Figure 1). The following sections will

128

narrate how clinical and economic outcomes from CMM services can benefit both third-party health plans

129

and primary care delivery systems through various mechanisms elucidated from the literature review.

130 131

CMM From a Third-Party Health Plan Perspective

132 133

The primary lines of business for third-party health plans include commercial plan contracts purchased by

134

fully-insured employers or individuals, Medicare Advantage (MA) plans, and state Medicaid managed

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care plans. CMM has the opportunity to benefit all lines of business through the following financing

136

elements: (1) increase market competitiveness, (2) increase direct revenue from capitated shared savings

137

contracts, and (3) achieve quality-related bonus payments.

138 139

Coverage of CMM services may increase health plan market competitiveness by lowering total medical

140

costs, thus allowing plans to offer lower premiums within the commercial market or lower their bids

141

within request for proposals (RFPs) to Medicare and Medicaid.32 In addition, CMM has the potential to

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increase market competitiveness by improving plan ratings. In the commercial market, the National

143

Committee for Quality Assurance (NCQA) accredits health plans and assigns plan quality ratings, both of

144

which are essential for winning contracts from large employers looking to provide a high-quality benefit

145

package to their employees.33,34 NCQA ratings and accreditation are based on achievement of HEDIS

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quality measures including processes (e.g. statin therapy in cardiovascular disease), outcomes (e.g.

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controlled A1c, reduction in hospitalizations), and patient experience measures.34,35 Over 30% of HEDIS

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quality measures are related to medications or medication-related treatment outcomes that are either a

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result of CMM MTP resolution (e.g. addition of an indicated statin) or that serve as a goal of CMM care

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(e.g. controlled blood pressure).35 Similarly, in the Medicare market, Star Ratings serve as a way to rank a

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high-quality plan. Of the 48 Stars Measures for 2018, 15 (31%) are either related to medication

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management (e.g. diabetes medication adherence, achievement of blood pressure control) or outcomes

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positively influenced by CMM such as hospital readmissions (see Table 1).36 In addition, these measures

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are more heavily weighted and end up contributing to greater than 31% of the calculated plan score. Of

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note, 66% of Medicare Advantage enrollees in 2017 were enrolled in a plan with a Star Rating of 4 or

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more Stars on the 5-Star scale, indicating the impact of high-quality ranking on member enrollment, and

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thus plan competitiveness.29

158 159

Through lowering the cost of care and higher achievement of quality measures, CMM can benefit plans’

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direct revenue for those engaged in capitated shared savings contracts such as the Medicare Advantage

161

payment system. In the MA market, plans submit bids to CMS that estimate the cost to cover an average

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beneficiary. Plans who submit bids lower than the CMS calculated benchmark rate have the opportunity

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to gain a portion of the “savings” (difference between the benchmark and plan bid).32 Lowering the total

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cost of care of a plan population through appropriate medication management can help plans achieve

165

lower bids and recoup a larger magnitude of savings.

166 167

Lastly, by improving HEDIS or Star quality measures, CMM has the potential to offer quality bonuses to

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plans. In the Medicare Advantage market, the proportion of savings that is repaid to Medicare Advantage

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plans, also known as the MA rebate, is entirely dictated by a plan’s Star Ratings. Known as a Quality

170

Bonus Payment, the CMS calculated benchmark is increased by 5% for plans who achieve a Star rating of

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4 or higher, allowing these plans to have a wider spread between their quality-adjusted benchmark and

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original plan bid. The shared savings’ rebate percentage that a plan recoups is also influenced by Star

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ratings. Plans with 4.5 stars or higher receive a 70% rebate, whereas plans with 3 stars or lower only

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receive a 50% rebate.37 Notably, quality bonus payments are also becomingly increasing more common in

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some state Medicaid programs such as New York, where plans may receive bonuses upon high quality

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measure performance.38

177 178

CMM From a Primary Care Practice Perspective

179 180

Primary care practices may be primarily funded through traditional fee-for-service (FFS) reimbursement

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or organized into models where care coordination, quality, and cost-effectiveness are emphasized such as

182

PCMHs or ACOs. Depending on the practice structure, CMM has the opportunity to benefit primary care

183

practices through three financing elements: (1) increased market competitiveness, (2) increased direct

184

revenue from traditional FFS payments or shared savings, and (3) quality bonus payments.

185 186

Integrating CMM into primary care practices can increase market competitiveness with consumers and

187

health plans. Consumers have demonstrated high patient satisfaction with CMM services and increased

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confidence in managing their diseases.5,6,11,15 Practices may use patient anecdotes as a marketing tactic to

189

increase patient volume. In addition, CMM can increase practices’ contract negotiating power with health

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plans. First, CMM can help improve quality metrics, patient satisfaction, and acute care utilization, which

191

provide important data that can be leveraged in insurer negotiations.6,9,18 Second, CMM implementation

192

can help with requirements for ACO or medical home accreditations, which are often required for

193

inclusion in payer networks. For example, NCQA’s PCMH recognition process requires team-based care,

194

delivery of guideline-directed care, medication education and counseling, establishment of person-

195

centered care plans for high risk patients, and other requirements that are essential components of the

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CMM care process that may otherwise not be formally integrated into the primary care practice.39

197 198

Pharmacist-delivered CMM services can also generate direct revenue from traditional FFS billing, PCMH

199

and ACO payments, and capitated shared savings. Although FFS reimbursement is often insufficient to

200

cover all costs associated with CMM, it can provide consistent supplemental revenue in addition to the

201

other economic benefits discussed in this framework. Certain states such as Minnesota have recognized

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the value of pharmacist CMM services and have created a FFS reimbursement structure to recognize

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CMM care delivery.7 In other states, FFS billing for CMM can either be achieved directly though current

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procedural terminology (CPT) code 99211 ($20-$30) or through physician “incident-to” billing for a

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variety of scenarios where reimbursement may range from $40 to $226 (see Table 2).40 These may

206

include transitional care management (CPT 99495, 99496), annual wellness visits (G0438, G0439), or

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newer chronic care management codes (CPT 99490).41 Practices have the opportunity to be innovative

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with the CMM care process in order to receive maximal reimbursement. Two real-world examples of this

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include incorporating Annual Wellness Visits into the CMM process29 and physician-pharmacist co-visit

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models that allow for physicians to see more patients daily and bill at a higher complexity.42 In addition,

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PCMH and ACO accredited practices can receive direct increases in their contract revenue in the form of

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additional care management fees or shared savings that are weighted based on quality.43,44 Lastly, by

213

lowering acute care utilization, CMM has the potential to increase shared savings for primary care

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practices where capitation is the primary reimbursement model such as in ACOs. As health systems take

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on more risk for attributed patient panels, investment in services that aim to manage chronic disease and

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prevent avoidable complications will be integral for driving revenue.45

217 218

Practices can also obtain quality bonus incentive payments with commercial and government payers

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through the Merit-based Incentive Payment System (MIPS) and pay-for-performance (P4P) models.46,47

220

Due to the recent Medicare physician reimbursement overhaul known as the Medicare Access and CHIP

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Reauthorization Act (MACRA) of 2015, primary care physicians will be engaged in upside-downside risk

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adjustments that can affect up to 9% of their Medicare reimbursements.47 These adjustments will be based

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on MIPS composite scores that incentivize quality, efficient resource utilization, practice quality

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improvement activities, and advancement of health information technology. As of 2019, 60% of the MIPS

225

score is made up of achievement of quality measures and resource utilization (i.e. cost of medical claims),

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which may be positively influenced by CMM interventions.47 Several MIPS quality measures are related

227

to chronic medication management such as evidence-based therapy for heart failure, improvement in

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blood pressure, and optimal asthma control.48 In addition to Medicare’s MIPS program, pay-for-

229

performance models are another form of quality bonus payments. P4P arrangements vary widely and are

230

ubiquitous across Medicare, Medicaid, and commercial contracts.46 P4P may be based on achievement of

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quality measures such as following guideline-based therapy or lowering acute care utilization, both of

232

which are supported by the CMM care model.

233 234 235

DISCUSSION

236

This study presents a novel conceptual framework describing the economic value proposition for CMM in

237

the U.S. healthcare system. The framework demonstrates aligned economic justification for CMM by

238

both primary care practices investing and implementing CMM and health plans providing coverage and

239

reimbursement of CMM services. Namely, health plans and primary care practices alike may improve

240

market competitiveness, increase direct revenue, and achieve quality bonuses by adopting and paying for

241

CMM. These financial opportunities posit a value proposition for CMM services in U.S. primary care

242

settings, which can aid greater numbers of practices to adopt CMM services. This work can serve as a

243

launching point for negotiations or business plan development for primary care practices looking to

244

convince health plans to reimburse for CMM within their contracts, or for pharmacists looking to

245

convince health system administrators to implement CMM services at their institutions.

246 247

In order to help promote effective expansion of CMM, stakeholders will have to be committed to

248

documentation and tracking of outcomes, partnering in quality-based analytics, and considering physician

249

buy-in. To promote CMM as a sustainable and integrated service within health system budgets, care

250

practices must be committed to tracking CMM interventions and outcomes. By continuously generating

251

evidence for CMM services, care practices will be able to leverage these outcomes in payer negotiations

252

and with health system leadership. These efforts can help move CMM funding from short-term and

253

limited sources to fully integrated into health system budgets. One potential innovation that may help

254

with tracking outcomes is the introduction of Systematized Nomenclature of Medicine - Clinical Terms

255

(SNOMED CT) codes, a new coding system to record care interventions in electronic health record

256

(EHR) systems. Adoption and consistent use of SNOMED CT codes as a way to track and monitor

257

interventions made by pharmacists can present an opportunity to make a more convincing value argument

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for CMM.49 In addition, health plans willing to recognize CMM in contract negotiations can also partner

259

with care practices to share and generate evidence for CMM patients utilizing claims-level data. This may

260

help further demonstrate the value of CMM services on a macro level.

261 262

The focal point of CMM revenue opportunities for health plans and primary care practices is centered

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around the achievement of value-based quality measures as well as lowering total medical costs. As the

264

sustainability of CMM implementation is based on these quality outcomes, practices and health plans

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should carefully consider quality measures they are held accountable for and create infrastructure to help

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improve those outcomes. Health plans should focus on using analytics to identify quality measure

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opportunities, enhance communication and data-sharing with providers and primary care practices to

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address those gaps, and support practice-level incentives for quality measures that can help fund and

269

sustain CMM services. Similarly, primary care practices should partner with health plans to leverage their

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data capabilities to identify and improve quality measure opportunities. Primary care practices should also

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ensure to educate providers and primary care team members about the importance of quality-based

272

initiatives and to develop agility in their care models in order to continuously address population-level

273

gaps in care.

274 275

While our conceptual framework focuses on a financial justification for CMM services, widespread

276

adoption of this care model also requires buy-in from providers. Fortunately, physicians in primary care

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practices that have fully adopted CMM have reported high satisfaction with CMM and improvement in

278

their work-life as a result of having pharmacist partners in their practices. Specifically, physicians have

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reported decreased workload, satisfaction that patients are receiving better care, reassurance, decreased

280

mental exhaustion, enhanced professional learning, increased provider access, and achievement of quality

281

measures.50 In order to duplicate these physician outcomes, primary care practices newly adopting CMM

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should ensure pharmacist CMM services meet the individual needs of the physician practice and are

283

integrated into the practice as a collaborative care model, not a separate, isolated function.

284 285

Widespread adoption of robust, pharmacist-delivered CMM care models in primary care settings can help

286

further transition the U.S. healthcare system into one that is patient-centric, holistic, and focused on value.

287

Through implementation of CMM services, pharmacists can work alongside physicians in medical home

288

models, play a vital role in the transition to value-based care, and enhance the success of the growing

289

number of primary care practices engaged in value-based models.

290 291

Limitations

292

There are a few limitations to this study. First, publicly-available information regarding commercial

293

contract data between employers and health plans as well as health plans and care practices is very

294

limited. Although the literature suggests that there is an increasing commercial focus on value and quality

295

measures, the magnitude and specifics of this change remains unknown. Second, this study focused on the

296

largest sources of health insurance in the U.S. and therefore, excluded smaller populations with very

297

unique contracts or delivery systems where patients seek care such as the Veterans Affairs (VA) and

298

uninsured patients. Third, this study focuses on the delivery of comprehensive, whole-patient-centered

299

CMM in primary care settings and does not focus on pharmacists providing care in specialty clinics.

300

Specialty-focused pharmacist services are less standardized across practice settings and associations to

301

various financial elements likely vary across individual practices.

302 303 304

CONCLUSIONS

305 306

This study presents a novel framework for justifying the adoption of pharmacist-delivered CMM services

307

in the U.S. By improving healthcare quality measures and decreasing acute complications of chronic

308

disease management, CMM can increase health plan and primary care practice market competitiveness,

309

direct revenue, and achievement of quality bonuses. The broad alignment of benefits that can be realized

310

across the healthcare system provides a strong value proposition for greater adoption of CMM services in

311

the U.S. primary health care system.

312 313

Funding Source: This research did not receive any specific grant from funding agencies in the public,

314

commercial, or not-for-profit sectors.

315 316

Competing Interests: The authors have no competing interests to disclose.

317

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Figure 1. Conceptual framework describing the economic value proposition for CMM within the U.S. healthcare system.

Abbreviations: ACO = accountable care organization, FFS = fee for service, MA = Medicare Advantage, MIPS = Merit-Based Incentive Payment System, NCQA = National Committee for Quality Assurance, P4P = pay for performance, PCMH = patient centered medical home, TPA = thirdparty administrator.

Table 1. 2018 Medicare STAR measures influenced by pharmacist CMM services. Annual flu vaccine Care for Older Adults – Medication Review Controlling Blood Pressure Diabetes Care - Blood Sugar Controlled Getting Needed Prescription Drugs Improving Bladder Control Medication Adherence for Diabetes Medications Medication Adherence for Hypertension (RAS antagonists) Medication Adherence for Cholesterol (Statins) Medication Reconciliation Post-Discharge MTM Program Completion Rate for CMR Osteoporosis Management in Women who had a Fracture Plan All-Cause Readmissions Reducing the Risk of Falling Rheumatoid Arthritis Management Abbreviations: CMR = comprehensive medication review, MTM = Medication Therapy Management, RAS = renin-angiotensin system Table 2. Billing codes related to CMM services. HCPCS Code Description Code CPT 99211

2018 Reimbursement Fee Schedule $22

Evaluation and management service office or other outpatient visit that may not require the presence of a physician CPT 99490 Chronic care management service – 20 $42 minutes CPT 99495 Transitional care management – 14-day $167 discharge CPT 99456 Transitional care management – 7-day $236 discharge G0438 Annual Wellness Visit – initial visit $175 G0439 Annual Wellness Visit – subsequent visit $119 Abbreviations: CPT = Current Procedural Terminology, HCPCS = Healthcare Common Procedure Coding System