- Medicare patient diagnosed with 2+ chronic conditions;
- A comprehensive patient-centered care plan must be in place;
- 20 minutes of non-face- to-face clinical staff time invested per calendar month;
- The provider must obtain the patients written consent;
- Only one provider can bill per patient per month.
Note the 3.7% increase in the CCM payment rate for 2017 :
This fact sheet provides background on the newly payable chronic care management(CCM) service, identifies eligible providers and patients, and details the Medicare PFS billing requirements.
Examples of chronic conditions include, but are not limited to, the following:
- Alzheimer’s disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Atrial fibrillation
- Autism spectrum disorders
- Cardiovascular Disease
- Chronic Obstructive Pulmonary Disease
- Infectious diseases such as HIV/AIDS
What types of chronic conditions are reimbursed under CCM?
# CMS maintains a Chronic Condition Warehouse (CCW) to provide researchers with beneficiary, claims, and assessment data linked by beneficiary across the continuum of care. The CCW includes information on 22 specified chronic conditions. However, the CCW list is not an exclusive list of chronic conditions, so CMS may recognize other conditions for purposes of providing CCM.
What level of professional can bill for the 20 minutes of non-face- to-face time?
# Physicians and the following non-physician practitioners may bill for the CCM service: Certified Nurse Midwives; Clinical Nurse Specialists; Nurse Practitioners; Physician Assistants. Eligible practitioners must act within their State licensure, scope of practice and Medicare statutory benefit. Services provided directly by an appropriate physician or non-physician practitioner, or other clinical staff “incident to” the billing physician practitioner, counts toward the minimum service time required to bill for CCM services per calendar month. Non-clinical staff time cannot be counted towards the minimum CCM monthly services; however, CCM services may be recorded by non-clinical staff
Is certified EHR technology (CEHRT) required for CCM billing? When any of the CCM scope of service elements refers to a health or medical record, the use of an EHR certified to either the 2011 or 2014 edition certification criteria is required to fulfill the scope of service element in relation to the health or medical record.
According to a national provider survey, regulatory complexity has been the primary obstacle to CCM adoption. In response, CMS proposes several revisions to the billing rules, all of which make it easier to provide these services.
- No required consent form.
Current rule: A physician cannot bill for CCM unless and until the physician secures the beneficiary’s signature on a consent form, the contents of which are specified in the regulation. Proposed rule: A physician may simply document in the medical record that certain information regarding CCM was furnished to the patient.
- Initiating visit.
Current Rule: CCM must be initiated by the billing physician during a face-to-face E/M visit (Levels 2-5 E/M visit, an annual wellness visit, or initial ‘Welcome to Medicare’ visit). Proposed Rule: Such initiating visit is required only for new patients and patients not seen within the last twelve months.
- 24/7 access to care.
Current Rule: The physician must provide the beneficiary with a means to make timely contact with healthcare practitioners in the practice who have access to the beneficiary’s electronic care plan. Proposed Rule: The requirement regarding access to the beneficiary’s care plan is eliminated.
- Management of care transitions.
Current Rule: The physician must create and exchange with other providers involved in the beneficiary’s care a clinical summary formatted according to certified EHR technology. Proposed Rule: The continuity of care document does not have to be formatted in a specific manner.
- Sharing of care plan and clinical summaries.
Current Rule: The physician must make the electronic care plan available (a) on a 24/7 basis to all practitioners within the practice whose time counts toward the time requirement, and (b) share care plan information electronically (by fax only in extenuating circumstances) as appropriate with other providers. Proposed Rule: The electronic care plan must be made available timely within and outside the billing practice as appropriate, and care plan information must be shared electronically (can include fax) within and outside the practice with those involved in the beneficiary’s care.
- Beneficiary receipt of care plan.
Current Rule: The beneficiary must be provided with a written or electronic copy of the care plan. Proposed Rule: The specification of the format in which the care plan is to be provided is eliminated.
Current Rule: A physician must document (in a qualifying certified electronic health record) communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits. Proposed Rule: Such communications must be documented in the patient*s medical record, but not necessarily a qualifying certified electronic health record.
CCM: What is it?
Under CPT code 99490, the 2017 average reimbursement is $45.00, adjusted based on geography.
- Only one clinician can furnish and be paid for CCM services during a calendar month. The clinician who is providing the primary care to the patient is the one who can bill. Usually this will be the primary care physician, but some specialists may be serving as the patient*s primary care physician.
- Copayments (coinsurance and deductibles) DO apply.
- The following codes cannot be billed during the same month as CCM (CPT 99490):
- Transition Care Management (TCM) – CPT 99495 and 99496
- Home Healthcare Supervision – HCPCS G0181
- Hospice Care Supervision – HCPCS G9182
- Certain ESRD services – CPT 90951-90970
- If other E&M or procedural services are provided, those services will be billed as appropriate. That time can NOT be counted toward the 20 minutes for CCM. If time – such as from a phone call – leads to an office visit resulting in an E&M charge, that time would be included in the billed office visit, NOT the CCM time.
Why start a CCM program?
Billing for CPT code 99490 can help you achieve:
CCM Goals: A Bridge to Value-based Care
Taken together, these proposed enhancements to Medicare reimbursement for ambulatory care management should give physician groups more reason to consider providing these services. In addition to generating immediate revenue, care management services engage patients, improve outcomes, and reduce overall total cost of care. Thus, a care management program can serve as a bridge between today’s fee-for-service reimbursement and emerging value-based alternative payment models.
This opportunity is not limited to primary care physicians. Specialists who provide care for patients with chronic conditions can customize care management programs to meet patients’ specific needs. For example, an oncology practice can fund chemotherapy patient navigator services through care management revenue. Again, these services improve patient satisfaction and care coordination, thus improving quality and efficiency.
With a greater percentage of reimbursement tied to value each year, developing and deploying a care management infrastructure today will improve value-based performance in the near future. Modest investments in necessary clinical staff and technology ‘either directly or through third-party contracts’ are a wise move in a changing healthcare environment.
Prepare for MACRA:
Recommendation from AAFP & ACP
- Document 20 minutes of non-face-to-face clinical staff time.
- A practice can insource or outsource the delivery of CCM services for its patients. In either case, the practice will need to establish a consistent system of documentation based on its own physical, staffing, and EHR configurations. Consideration should include documentation of care provided by both internal and external individuals (such as for call coverage), who and how care will be documented in the record, and how to document time spent delivering various aspects of care and care coordination. It is possible that there will not be a CCM code billed for every patient every month, since some months may not generate 20 minutes of care coordination.
- If after hours care is provided by a clinician who is not part of the practice, such as for call coverage, that individual must have access to the electronic care plan (other than by facsimile). The care plan may be accessed via a secure portal, a hospital platform, a web-based care management application, a health information exchange, or an EHR to EHR interface.
- Services can be provided “incident-to” the designated clinician if the CCM services are provided by licensed clinical staff employed by the clinician or practice who are under the general, not necessarily the direct, supervision of the designated clinician. The normal “incident-to” documentation requirements apply.
- Contracted clinicians count as long as they have access 24/7 to the patient’s electronic record and are under the general supervision of the CCM physician or “eligible practitioner.”
Chronic Care Management Services
Why should I use HSK to provide this service? Can’t I do it myself?
You could do it yourself, but do you want to?
- There’s a minimum of 20 minutes per month, and you’re required to the full scope of services each and every month. We know that it takes quite a bit more time every month.
- We have to stay in contact with the patients, their families, and every one of their other providers.
- We’ve already created a secure collaboration platform and Care Reports that go beyond the CMS requirements.
- We speak your patient’s language such as Chinese, Korean, Spanish and Etc.
- Same person for all your patients (same phone number and same staff).
- Daily Reports (If request)
NO RECRUITING, NO HIRING, NO HASSLE CMS requires 20 minutes minimum per patient per month to bill for CCM – this time adds up quickly. For 500 patients this could range from 2 to 3 additional fulltime employees (FTEs) to recruit, hire and manage – not to mention the additional office space!