On January 1st, 2015, the Centers for Medicare and Medicaid Services (CMS) started reimbursing providers who actively manage care delivery for Medicare patients suffering from two or more chronic conditions. Providers are required to provide at least 20 minutes of follow-up care outside of the office (non-face- to-face care).
Medicare has stated that they plan to monitor and update CCM requirements on an ongoing basis. There is no indication that the program will be discontinued. CCM was specifically addressed in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which outlined numerous addressed certain requirements in the CCM program, he CCM program is being continued for will continue indefinitely. reimbursement are not Medicare Physician Fee Schedule.
Medicare estimates that 2 out of every 3 Medicare beneficiaries, roughly 35 million patients, would qualify for CCM services.
The average compensation, depending on geographic area, for providing CCM services is approximately $42 per month/per patient.
100 patients per month for CCM services, they would generate $50,400 in additional revenue from their current Medicare patients.
200 patients per month for CCM services, they would generate $100,800 in additional revenue from their current Medicare patients.
Practitioners may bill for CCM services for a patient each month, using CPT code 99490, whenever the following criteria are met:
The healthcare providers meets with the patient during a face-to- face visit for an E/M service (e.g., 99213), discusses the program, and obtains written consent from the patient.
The provider and his/her staff create a comprehensive care plan
The consent form and comprehensive care plan are stored in a certified electronic health record (EHR)
Following this each time a clinical staff member speaks with the patient over the phone, communicates through the patient portal, or otherwise provides non-face- to-face care the amount of time spent is recorded.
Once the amount of non-face- to-face care time reaches 20 minutes in a single calendar month, the provider can bill for the services using CPT code 99490.
The provider must designate someone on their staff to be the single point of contact for the patient
The provider's practice must offer 24/7 access to a provider in the same practice (or cross-covering providers) to each patient enrolled in the CCM program.
The comprehensive care plan also needs to be available to providers caring for the patient.
Standard documentation principles apply.
For example, a registered nurse speaks with a patient and the conversation results in a change in their medications.
The time the nurse spends with the patient, interacting with a physician, creating a note and updating the medication list in the EHR would all countstowards time spent providing care under the CCM program.
As with any documentation, the identity of the clinical staff member and the date/time of the encounter should be recorded.
However, with CCM services, the amount of time spent providing and recording the service and updating the patient's record, also needs to be documented.
Medicare Part B patients with no secondary coverage will be responsible for about $8/month. However, many Medicare patients have co-insurance that will cover the copayment fee.
Surveys have in general identified three areas that have contributed to slow adoption of CCM services, despite the program's value to patients and practices.
Lack of familiarity with the CCM program
Concerns about compliance and workflow
Insufficient reimbursement for the time required
(Note: All three of these issues are extensive addressed by CCMTrack and services).
Explaining the value of the program to patients should help. Medicare has created this program in an effort to expand the level of care provided by medical practices. These additional efforts will help patients remain out of the emergency room and the hospital. It will help them avoid unnecessary tests and referrals, and reduces medical errors through better communication between healthcare providers. It will also help understaffed medical practices hire additional employees that can help patients in many different ways.
Not if the time spent with the patient is a component of a billable home health service, or if the provider is overseeing (and billing for) home health services.
At least 20 minutes of non-face-to-face care to Medicare beneficiaries enrolled in CCM during a given month is required. This service must be delivered during that billing month and cannot be applied to future months.
Non-face-to-face care management services may be furnished inside or outside of the provider's office, however they must be services that are normally provided in a non-face- to-face setting. Clinical staff must perform these services under the general supervision of a physician (not necessarily the billing physician).
This time could be applied toward the required 20 minutes, if performed by licensed clinical staff.
In many states certified MAs can provide CCM services. The term Clinical Staff Members is defined by the AMA in the Current Procedural Terminology code book. It is defined as a person who, under the supervision of a practitioner, is allowed by law, regulation, or facility policy to perform or assist in the performance of a specified action. Clinical competency should be determined by the physician in conjunction with state regulations, patient needs, etc.
CMS has stated they have left the determination of what should be considered a chronic condition open to the provider. The guideline simply requires:
Multiple (two or more) chronic conditions expected to last at least 12 months, and that put the patient as significant risk of disability or death.
A provider cannot bill for CCM unless and until the provider secures the beneficiary's written consent.
A beneficiary must acknowledge in writing that the provider has explained the nature of CCM
How services can be accessed
That only one provider can bill for CCM
The beneficiary's health information will be shared for the purpose of care coordination
The beneficiary may stop CCM at any time by revoking consent
The beneficiary will be responsible for any associated co-payment or deductible
This has not been directly addressed, however, at this time we are not recommending that CCM services be billed unless the time spent with the patient is during a one-on- one session.
CMS's intent was to have primary care be the primary beneficiary of the CCM program, however any eligible Medicare provider may perform and bill for CCM services.
Yes, specialists such as cardiologist and oncologists can provide chronic care management services.
CMS requires the billing practitioner to initiate the CCM service as part of an Annual Wellness Visit, Initial Preventive Physical Examination, or comprehensive evaluation and management visit to the patient prior to billing. CCM can be billed for this first month if the consent form is signed.
Only one provider may bill on any given month. The patient must notify the provider in writing, and the service will cease on the last day of that month.
There is no standard form. However, typical components of care plan are:
Problem list, expected outcome and prognosis
Measurable treatment goals
Symptom management and planned interventions
All recommended preventive care services
Plan for care coordination with other providers
Medication management, including a list of current medications and allergies
Requirements for periodic review
Similar documentation used for an annual wellness visit
The provider should have the capability to transmit the summary care record and the care plan electronically but not through facsimile.
Patient portals are understood to be one way of helping to address or support certain CCM requirements that relate to the care plan and provider access. There is no specific requirement that ties the provision of a patient portal to Medicare's CCM program, however, there are requirements associated with Meaningful Use that directly relate to patient portals.
Generally, it means patients must be able to reach a member of the care team 24 x 7 for direction and support. For example, rather than leaving a message on an answering machine that directs CCM patients to the closest emergency room, practices should have a system that enables patients to discuss symptoms with a physician, or another care team member, in order to determine the most appropriate health intervention.
Yes. Below services cannot overlap with CCM services on the same day, if billed by the same practice:
Transitional Care Management (99495, 99496)
Home Healthcare Supervision (G0181)
Hospice Care Supervision (G0182)
Certain ESRD codes (90951-90970)
Yes, this would be considered a non-face- to-face service and offers additional benefits to patients.
Medicare and Medicare Advantage plans. A few selected private carriers are offering CCM plans, however this remains primarily a service for Medicare beneficiaries.
The average reimbursement is about $42, but this varies by geographic region.