Chronic Care Management Services: Requirements and Legal and Compliance Activities

Chronic care management (CCM) services are now eligible for Medicare reimbursement to physicians and other qualified health care practitioners (OQHPs), such as nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants. Beginning on January 1, 2015, a per beneficiary, once per calendar month fee is payable for qualifying non-face-to-face care coordination and care management services of at least twenty (20) minutes of clinical staff time provided or directed by the physician or OQHPs to eligible Medicare beneficiaries.

Eligible Medicare beneficiaries are patients with two or more chronic conditions expected to last at least twelve months, or until the patient’s death. Chronic conditions are those that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. The Centers for Medicare and Medicaid Services (CMS) maintains a Chronic Condition Warehouse that includes information on 22 chronic conditions. CMS may add more chronic conditions. No information has been provided by CMS on how to determine or document the specific acuity level of a chronic condition.

CCM services are limited to Medicare patients residing at home or in a domiciliary, rest home or assisted living facility. CCM services cannot be billed for patients attributed to medical practices for participation in the Multi-payer Advanced Primary Care Practice Demonstration or the Comprehensive Primary Care Initiative. These initiatives pay for services similar to CCM. Hospitals, nursing homes and skilled nursing facilities are ineligible for CCM reimbursement because care management activity by facility staff for inpatients or residents is included in their associated facility payments.

With approximately 2/3 of the Medicare population eligible, CCM is designed to be a critical component of primary care that contributes to improved health and reduced expenditures for the program and its beneficiaries. Payment for CCM finally acknowledges the amount of time that physicians and their clinical staff spend managing and coordinating care for chronically-ill Medicare patients outside of an office visit.

Two sets of Medicare Physician Fee Schedule (MPFS) rules apply to CCM services and reimbursement (available on the CMS MPFS web page). Most CCM requirements appeared in the CY 2014 MPFS final rule. The CY 2015 MPFS final rule addressed valuation of the CCM CPT code, a general supervision exception to the incident-to rules, CCM service elements that must use certified electronic health record technology (CEHRT), and CCM’s relationship to advanced primary care demonstration projects.

CMS has also listed Frequently Asked Questions dealing with the relationship of CCM to Primary Care Medical Home Demonstration Practices (updated on 2/9/2015), issued a CCM Services Fact Sheet (ICN 909188, January 2015), and conducted a national provider call (slide presentation, audio recording and written transcript available on the MLN Connects National Provider Call web page). Unfortunately, the Fact Sheet conflicts with the MPFS rules (the rules govern) and CMS punted decisions and guidance on several CCM issues to the Medicare Administrative Contractors (MACs).

Medicare will pay new CPT code 99490 for CCM services. CMS did not develop a HCPCS code to describe CCM. In order to prevent duplicate payments for similar services, CCM services are bundled into 99490. Similar services may not be billed separately when CCM is billed for the calendar month.

Due to a lack of explanation in the MPFS final rules and CPT manual, legal and compliance risks have arisen for CCM coding, documentation, billing and reimbursement. CMS did not establish a new set of standards for billing CCM services. Instead, CMS decided to emphasize that certain requirements are inherent in the elements of the existing scope of services, and stated that these requirements must be met in order to bill CCM services. These requirements are complex and ill-defined. The CCM requirements and legal/compliance activities are described below.

Patient Information and Consent

Prior to initiating CCM services, the medical practice must obtain the patient’s written consent to the furnishing of CCM services. The consent must be included in the patient’s medical record. The consent must take the form of a voluntary, informed beneficiary agreement that discusses:

• Availability and description of non-face-to-face CCM services;
• Payment of any deductible and $8.50 coinsurance per monthly CCM claim;
• Authorization for the electronic communication of the patient’s medical information to other treating providers as part of care coordination;
• Provision of a written or electronic copy of the care plan to the beneficiary;
• Limitation of only one practitioner being paid for CCM services during the calendar month; and
• Right to revoke CCM consent at any time and the effect of revocation on CCM services.

The consent process is not separately billable as a CCM service. The 2014 MPFS rule recommends that consent to CCM be discussed at a face-to-face visit such as an annual wellness visit, the initial preventive physical examination or regular evaluation and management (E&M) visit.

Legal/Compliance Activity: CMS did not provide a model consent form or specify the effect of a declination or revocation of CCM. If the beneficiary declines the CCM services, or revokes the CCM consent, the practice will need to decide the scope of care coordination and care management services it will provide to declining/revoking patients. What type and amount, if any, of CCM services will such patients be provided? Does the type and amount of CCM services that the practice provided prior to the CCM benefit represent a standard of care? Do medical risks arise for such patients if the practice terminates some or all of the existing CCM services?

CCM Coding and Billing Requirements

Payment in DFW is $42.60 per patient per month if 20 or more minutes of qualifying CCM is provided in the calendar month.

Legal/Compliance Activity: Monthly CCM payment is not automatic. CCM services of less than 20 minutes in duration in a calendar month may not be reported or billed to Medicare for CCM reimbursement. Standard CMS time-based counting rules of rounding up from the midpoint do not apply. Aggregating CCM services over 2 or more months is prohibited. Tracking, recording time and managing the coding exceptions applicable to non-face-to-face services is not a typical activity for medical practices. Few, if any, CEHRT contain software for CCM tracking, logs or service templates. Medical practices may need to make software additions or changes to address documenting and reporting CCM services.

Medicare deductible and coinsurance will apply because CCM is not a preventive service and exempt from beneficiary cost-sharing. Patients will pay $8.50 in coinsurance.

Legal/Compliance Activity: Medicare beneficiaries may question why an $8.50 monthly payment is required from them. Many physician practices are currently performing some CCM services without compensation or patient awareness of the services—some beneficiaries may be reluctant to pay for services they were receiving for free. Beneficiaries may be hesitant to pay coinsurance for services that are provided in a non-face-to-face manner. Beneficiaries with supplemental coverage will have the monthly coinsurance covered. Some medical practices estimate that billing and collecting the coinsurance will cost more than $8.50 per patient. Considering the beneficiary inducement and waiver of Part B coinsurance prohibition, what will the practice’s policy be for patients who do not pay the coinsurance?

CCM services are not reimbursable if provided on the same day that an E&M visit occurs. The same clinical staff time cannot be attributed to both CCM services and the E&M visit—no “double-dipping”. E&M services may be reported and billed anytime within the calendar month that CCM services are reported. If several members of the care team are discussing a beneficiary’s chronic care management, the time spent by only one of the multiple staff members may be counted toward the 20 minutes required to bill 99490.

Several medical services may not be billed in addition to CCM during the same calendar month for the same Medicare patient because CCM encompasses such services. Providers may have a choice of code decision to make between CCM and any one of the following codes. The following services/codes may not be reported and billed separately during the month that CCM is reported and billed:

• Care plan oversight (CPO) services (99339, 99340, 99374-93380),
• Prolonged services without direct patient contact (99358-59),
• Anticoagulant management (99363-64),
• Medical team conferences (99366-68),
• Education and training (98960-62, 99071,99078),
• Telephone services (99366-68, 94441-43),
• Online medical evaluation (98969,99444),
• Preparation of special reports (99080),
• Analysis of data (99090-91),
• Transitional care services (99495 or 99496),
• Home health care supervision (G0181),
• Medication therapy services (99605-07), and
• Hospice care supervision (G0182).

Also, CCM may not be reported when providing end-stage renal disease services (90951-90970) or during the postoperative period of a reported surgery.

Other significant CCM coding, billing and reimbursement rules (or omission of rules) include:

• Physicians and other OQHPs are eligible to bill Medicare for CCM. Texas physician assistants must be an employee of the medical practice under a valid employment arrangement in order to bill Medicare.
• CMS will pay only one CCM claim per beneficiary per month. If competing claims are submitted, the MAC will likely pay the provider with the most recent valid patient consent.
• CCM is not included as a rural health clinic (RHC) or federally-qualified health center (FQHC) service so those clinics will not be reimbursed for providing CCM services. The clinics must meet applicable requirements to bill the services as non-RHC or non-FQHC services under the MPFS.
• Revocation of patient consent is applicable at the end of the calendar month in which the revocation is made—either by the patient directly in writing or by the patient’s written valid CCM consent with another provider. A medical practice may be paid for 20 minutes of CCM provided in the month in which the patient revoked his CCM services consent.
• Neither MPFS nor the CPT manual provides guidance on how to document the provision of CCM services in the medical record for billing purposes. As with other time-based services, the provider’s template should contain date, service time start and stop, description of the service and name/credentials of the clinical staff.
• CMS states that CCM includes time clinical staff spend reviewing remote monitoring of patient’s physiological data, but cannot count the time the patient spends monitoring or wearing the monitoring device.
• On the national provider call, CMS stated there are no CCM claim edits for date of service, site of service or diagnosis codes. Consequently, CCM claims should not be denied for errors or omissions of such information (check with the MAC). A provider does not have to wait until the end of the calendar month to submit the CCM claim. A claim may be submitted as soon as the 20 minutes of CCM services has been performed.
• Also on the call, CMS did not definitively discuss billing guidance for physicians providing or supervising CCM services in a hospital outpatient department. Such physicians are eligible for CCM reimbursement and are paid at a facility rate for physician services that is $9-$10 less than the non-facility rate. The hospital should bill the facility rate for costs related to the hospital’s clinical staff providing CCM services in the outpatient department and other related costs.
• Despite referring questions about Medicare Advantage (MA) plans and CCM services to the MACs, MA plans should be paying for CCM services as they pay for other physician services that are Medicare benefits. Questions may arise about MA plans that require the provision of CCM-type services in their provider contracts without compensation.

CCM Care Plan

CPT code 99490 and the 2014 MPFS rule require that a comprehensive, patient-centered, electronic care plan consistent with the patient’s choices and values be established, implemented, revised and monitored. It must be based a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports available to and/or used by the patient, and is a comprehensive care plan to address all health issues.

The preparation and updating of the care plan is not reportable, billable or reimbursable as a CCM service. Such activities may be reimbursable separately as part of an E&M service if applicable requirements are satisfied.

Legal/Compliance Activity: CMS does not specify the elements of a comprehensive care plan. CMS suggested the following elements as typical of care plans for chronically ill patients:

• Problem list, expected outcome and prognosis and measurable treatment goals;
• Symptom management, planned interventions and identity of the individuals responsible for each intervention, and medication management;
• Community/social services ordered and a description of how direction/coordination of agency services and specialists unconnected to the CCM-billing practice will occur; and
• Requirements for periodic revision and, when applicable, revision of the care plan.

Legal/Compliance Activity: Given that the care plan is one of the three required elements of CPT code 99490, medical practices should be particularly diligent in the regular development and revision of the care plan based on the documentation of CCM services, the summary clinical record and structured recording of the patient’s chronic condition status and treatment. MACs and other CMS contractors will likely focus on the care plan in their audits of CCM services.

CCM Services

CMS requires the following scope of CCM services must be offered and available to the patient:

• Provision of 24/7 access to care management services, including a means for the patient to make timely contact with the practice’s providers to address urgent chronic care needs at any time;
• Care management for the patient’s chronic conditions including:
  • Systematic assessment (monitoring) of medical, functional and psychosocial needs;
  • System-based approaches to ensure timely receipt of all recommended preventive services;
  • Medication reconciliation with review of adherence and potential interactions;
    and
  • Oversight of the beneficiary’s self-management of medications;
• Management of care transitions (specialty referrals and discharges from health care facilities) with electronic communication (other than fax) of a summary care record between and among health care providers and settings;
• Care coordination and communication with home and community-based clinical service providers that must be electronically documented in the patient’s record;
• Continuity of care with the designated member of the care team with whom the patient has successive, routine appointments; and
• Enhanced opportunities for beneficiary and care team communication through telephone access and the use of secure messaging, Internet or other asynchronous non-face-to-face consultation.

Legal/Compliance Activity: The physicians, APNs, PAs and other clinical staff providing CCM services may be employees, leased employees or independent contractors of the medical practice. Licensed or certified clinical staff may provide CCM services (check State law). The medical practice may engage third parties to provide the CCM services. Non-clinical staff’s performance of CCM services is not reportable, billable or reimbursable by Medicare.

Use of CEHRT

Technology is an important part of CCM. CMS requires use of certified EHR technology–for CY 2015, an EHR certified according to the 2011 or 2014 criteria for the EHR Incentive Programs. CEHRT must be used to create two CCM core technology capabilities to inform the care plan, care coordination and ongoing clinical care:

• A structured, clinical summary record, and
• Structured recording of demographics, vital signs, problem list, and active and past medications and medication allergies.

Although meaningful use requirements do not have to be met, the care team must use CEHRT to meet the CCM core technology capabilities and to fulfill the CCM scope of services whenever the MPFS requirements reference a health or medical record. Consequently, EHRs must support the workflow and documentation of CCM services.

The care team must have 24/7 electronic access to the care plan as part of providing 24/7 response to chronic care patients for their urgent care problems. The care plan itself does not have to be created or transmitted using CEHRT. Electronic tools or services used by the practice for electronic transmission of patient information and 24/7 access are not specified.

Legal/Compliance Activity: Medical practices may have to acquire new software or modify existing software to develop the CCM core technology capabilities. Small and solo medical practices may find it difficult to provide CCM services due to the technology requirements unless they outsource.

General Supervision Permitted

CCM services may be provided and billed directly by physicians or OQHPs, or provided incident-to the billing professional’s services. Typically, incident-to services are provided under the professional’s direct supervision in order to be billed to Medicare under his provider number. CCM requirements mandate 24/7 access to CCM services and non-face-to-face services that may often be performed outside the office. The physician or OQHP may be unavailable to directly supervise such services.

Consequently, CMS made CCM an exception to the incident-to rule and requires only general supervision for CCM services. General supervision is not defined in the MPFS CCM rules. General supervision is considered to be services “under the professional’s overall control but without his physical presence” under other Medicare rules governing home health services.

Legal/Compliance Activity: A medical practice written policy on general supervision is necessary to comply with CMS’s direction that there be sufficient oversight demonstrating ongoing participation of the professional in the patient’s care and that CCM is being delivered as part of the prescribed course of treatment.

Complex Chronic Care Management

CMS is not covering and paying for complex chronic care management (CCCM) services (CPT codes 99487 and 99489) in 2015. CMS will evaluate the use of CCM services to determine what types of beneficiaries receive the services and what types of practitioners are reporting CCM services. CMS will consider any payment that may be warranted in the future. The CCCM CPT codes may be reported as “B” (Bundled) for 2015.