BALANCING KIDNEY CARE

MATCHING PATIENTS TO PROGRAMS FOR SUCCESS IN FFS AND VBC

ft. Jennifer Huneycutt CPA, CMPE of Metrolina Nephrology Associates

Chronic Care Management FAQ

Chronic care management (CCM) is a Medicare Fee for Service (FFS) program that is a critical component of healthcare for Medicare beneficiaries with two or more chronic conditions. Chronic care management services promote better health and reduce overall health care costs.

CCM services allow a healthcare provider to manage and coordinate patient care between traditional office visits. CCM services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. With CCM, the patient’s care team can bill for time spent managing the patients’ conditions.

CCM is covered under Medicare Part B and hence both Traditional Medicare and Medicare Advantage plans reimburse providers when CCM services are provided to eligible patients.

CMS is making chronic care management a top strategic priority in 2022 with reimbursement increasing 54%.  This article describes the key changes in 2022 to Medicare’s care management programs.  Here is a link to Medicare’s 2022 Physician Fee Schedule Final Rule along the the supporting data here.

Chronic care management services are important to improve the quality of care for Medicare beneficiaries and reduce healthcare costs. CCM is a proactive form of healthcare. Patients with two or more chronic conditions account for the majority of healthcare costs in the United States. Those patients don’t get enough proactive care. On average, Medicare patients see their healthcare provider three times a year and the other 362 days, they’re on their own. High-quality CCM has been proven to reduce costs and improve quality. CCM lowers hospitalization and ER visit rates and increases primary care visits.  As discussed in this report from Mathematica, the estimated PBPM impact of CCM on total expenditures were as 

follows:

 

All CCM patients

  • 12 month follow up period:  $28 decrease in PBPM
  • 18 month follow up period:  $74 decrease in PBPM

 

Excluding patients that received only one month of CCM services

  • 12 month follow up period:  $49 decrease in PBPM
  • 18 month follow up period:  $95 decrease in PBPM

 

Chronic care management is beneficial for patients in terms of ongoing health and wellness support, increased access to appropriate care, enhanced communication with their care team, reduction in emergency room visits and hospitalization or readmissions, and increased engagement in their own healthcare.

Get reimbursed for work that historically has been done for free

Reduce provider burnout by enabling the provider’s clinical staff to take on the CCM services

Improve quality of care for patients

Increase patient satisfaction

Increase patient retention

Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are eligible for CCM services.

According to the Medicare Learning Network booklet, the following are the key service requirements for CCM:

Initiating Visit

Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visit not required), for new patients or patients not seen within 1 year prior to the commencement of CCM services.

Structured Recording of Patient Information Using Certified EHR Technology Structured recording of demographics, problems, medications, and medication allergies using certified EHR technology. A full list of problems, medications, and medication allergies in the EHR must inform the care plan, care coordination, and ongoing clinical care.

24/7 Access & Continuity of Care

  • Provide 24/7 access to physicians or other qualified health care professionals or clinical staff, including providing patients/caregivers with means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week
  • Continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments
  • Comprehensive Care Management – Care management for chronic conditions including systematic assessment of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.

Comprehensive Care Plan

  • Creation, revision, and/or monitoring (as per code descriptors) of an electronic person-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues with particular focus on the chronic conditions being managed.
  • Must at least electronically capture care plan information and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the patient’s care.
  • A copy of the plan of care must be given to the patient and/or caregiver

Management of Care Transitions

  • Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and followup after discharges from hospitals, skilled nursing facilities, or other health care facilities
  • Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers

Home- and Community-Based Care Coordination

  • Coordination with home- and community-based clinical service providers
  • Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record 

Enhanced Communication Opportunities – 

Enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods.

Patient Consent

  • Inform the patient of the availability of CCM services; that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month)
  • Document in the patient’s medical record that the required information was explained and whether the patient accepted or declined the services 

Examples of chronic conditions include, but are not limited to, the following: 

  • Alzheimer’s disease and related dementia 
  • Arthritis (osteoarthritis and rheumatoid) 
  • Asthma 
  • Atrial fibrillation 
  • Autism spectrum disorders 
  • Cancer 
  • Cardiovascular Disease 
  • Chronic Obstructive Pulmonary Disease 
  • Depression 
  • Diabetes 
  • Hypertension 
  • Infectious diseases such as HIV/AIDS
  • For more, check out this Chronic Conditions Data Warehouse

Activities that count towards CCM include:

  • Phone calls and patient questions 
  • Medication refills and adjustments 
  • Scheduling, referrals, and prior authorizations 
  • Care planning and care coordination

Clinical staff will provide CCM services incident to the services of the billing physician (or other appropriate practitioner who can be a physician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife).  Time spent by clinical staff may only be counted if Medicare’s “incident to” rules are met such as supervision, applicable State law, licensure and scope of practice. If the billing physician (or other appropriate billing practitioner) provides CCM services directly, that time counts towards the 20 minute minimum time. Of course, other staff may help facilitate CCM services, but only time spent by clinical staff may be counted towards the 20 minute minimum time.

 

CPT defines a clinical staff member as “a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service; but who does not individually report that professional service.”

 

The Centers for Medicare and Medicaid Services (CMS) provided an exception under Medicare’s incident to rules that permits clinical staff to provide the CCM service incident to the services of the billing physician/practitioner under the general supervision  (rather than direct supervision) of a physician/practitioner. “General supervision” means the service is furnished under the billing physician/practitioner’s overall direction and control, but that person could be on call and not necessarily on site in the office.

Yes.  Specialists can provide and bill for Chronic Care Management services.  

 

However, the CCM service is not within the scope of practice of limited-license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.

Chronic Care Management (CCM)

Manage patients with two or more chronic conditions

Telehealth

Manages any patient – more generalized 

Remote Patient Monitoring (RPM)

Manage patients with one chronic condition 

Remote Therapeutic Monitoring (RTM)

Patients are self-managed by data reporting devices

Behavioral Health Integration (BHI)

Connects the medical professionals to the patient and their family to address medical conditions and related behavioral health factors that affect health and well-being

Transitional Care Management (TCM) 

Helps patients transition from inpatient care to a community setting

Annual Wellness Visits (AWV)

A review of the patient’s overall wellness and development of a personalized prevention plan

CCM Reimbursement & Billing

Resource for medicare chronic care management reimbursement

https://phamily.com/ccm-cpt-codes/

  • CPT 99490 – Chronic Care Management Services
  • HCPCS G0511 – General Care Management Services (for FQHCs/RHCs)
  • HCPCS G0506 – Comprehensive Assessment & Care Planning
  • CPT 99439 – non-complex CCM Add-on (New in 2021. Previously G2058)
  • CPT 99487 – Complex Chronic Care Management Services
  • CPT 99489 – Complex CCM Add-on
  • CPT 99491 – Physician-provided CCM

Yes, it depends on the plan. From our experience, most Medicare Advantage plans do pay for CCM.

Yes, on a state-by-state basis.

Yes, Care management services can be billed either alone or on a claim with an RHC or FQHC billable visit.

You can’t do CCM for patients attributed in your CPC+ Program, but you can do it for patients that are not attributed to CPC+ such as Medicare advantage patients, or in some states, Medicaid patients

CPT 99490 describes activities that are not typically or ordinarily furnished face-to-face, such as telephone communication, review of medical records and test results, and consultation and exchange of health information with other providers. If these activities are occasionally provided by clinical staff face-to-face with the patient but would ordinarily be furnished non-face-to-face, the time may be counted towards the 20 minute minimum to bill CPT 99490.

Under longstanding Medicare guidance, only one E/M service can be billed per day unless the conditions are met for use of modifier -25. Time cannot be counted twice, whether it is face-to-face or non-face-to-face time, and Medicare and CPT specify certain codes that cannot be billed for the same service period as CPT 99490 (see #13, 14 below). Face-to-face time that would otherwise be considered part of the E/M service that was furnished cannot be counted towards CPT 99490. Time spent by clinical staff providing non-face-to-face services within the scope of the CCM service can be counted towards CPT 99490. If both an E/M and the CCM code are billed on the same day, modifier -25 must be reported on the CCM claim.

Just like any other Medicare service, there may be a co-pay depending on the patient’s insurance plans.  Most Medicare patients (80%) have a supplemental plan that helps cover co-pays. Therefore, most patients bear no out-of-pocket costs for CCM. It is essential to explain the program correctly to your patients.  Even the small % of patients that may have co-pay, if they understand that this program is vital for their health just like the medication you prescribe and this program can help them stay out of the hospital, they will realize a small cost per month is worth it to avoid a hospital / ER / urgent care visit, which would cost them much more.

Yes. Previously, CCM time couldn’t be billed in the same month for a patient that you are already billing TCM time for. This change now allows you to bill for both TCM and CCM in the same month for the same patient when “reasonable and necessary”.

At least 20 additional minutes of care are required to bill the CPT 99439.

The service period for CPT 99490 is one calendar month, and CMS expects the billing practitioner to continue furnishing services during a given month as applicable after the 20 minute time threshold to bill the service is met (see #3 above). However, practitioners may bill the PFS at the conclusion of the service period or after  completion of at least 20 minutes of qualifying services for the service period. When the 20 minute threshold to bill is met, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month.

Practitioners must report the POS for the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient). Accordingly, practitioners who furnish CCM in the hospital outpatient setting, including provider-based locations, must report the appropriate place of service for the hospital outpatient setting). Payment for CCM furnished and billed by a practitioner in a facility setting will trigger PFS payment at the facility rate.

If all the CCM billing requirements are met and the facility is not receiving payment for care management services (for example, the beneficiary is not in a Medicare Part A covered stay), practitioners may bill CPT 99490 for CCM services furnished to beneficiaries in skilled nursing facilities, nursing facilities or assisted living facilities. The place of service (POS) on the claim should be the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient) as per #5 above. 

Yes, as provided in the CY 2014 final rule (78 FR 74425), CCM must be initiated by the billing practitioner during a “comprehensive” Evaluation & Management (E/M) visit, annual wellness visit (AWV) or initial preventive physical exam (IPPE). This face-to-face visit is not part of the CCM service and can be separately billed to the PFS, but is required before CCM services can be provided directly or under other arrangements. The billing practitioner must discuss CCM with the patient at this visit. While informed patient consent does not have to be obtained during this visit, it is an opportunity to obtain the required consent. The face-to-face visit included in transitional care management (TCM) services (CPT 99495 and 99496) qualifies as a “comprehensive” visit for CCM initiation. Levels 2 through 5 E/M visits (CPT 99212 through 99215) also qualify; CMS is not requiring the practice to initiate CCM during a level 4 or 5 E/M visit. However CPT codes that do not involve a face-to-face visit by the billing practitioner or are not separately payable by Medicare (such as CPT 99211, anticoagulant management, online services, telephone and other E/M services) do not meet the requirement for the visit that must occur before CCM services are furnished. If the practitioner furnishes a “comprehensive” E/M, AWV, or IPPE and does not discuss CCM with the patient at that visit, that visit cannot count as the initiating visit for CCM.

Implementing Chronic Care Management

Yes, however, these services must be furnished within the United States.  According to CMS, “CCM services can be subcontracted outside the practice to a US company, providing services in the US and all rules for billing CCM to the PFS are met.  There is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9).” 

 

The Final Rule relaxed the “Incident to” requirements of delivering non-face-to-face services under this code because CMS determined that the delivery of these services is not dependent upon the nature of the employment or contractual relationship between the clinical staff and the provider. CCM refers specifically to non-face-to-face services performed on behalf of a qualified patient. CMS states that the requirement of a direct employment relationship or direct supervision is unnecessary. It is also true that services are frequently provided outside of normal business hours or while the physician is away from the office during normal business hours. 

Pros: 

  • Improved Relationships with Patients
  • maintain control over the entire process from hiring and/or training staff, to managing their reputation.
  • New Revenue Streams
  • Staff Engagement

Cons: 

  • Upfront Financial Investment
  • Training
  • Regulations and Codes

Patient Enrollment

Yes, patient consent is required beforehand and ensures the patient is aware of cost-sharing (if any) and engaged throughout the process. Patient consent helps to avoid duplicative cost-sharing. Patient consent may be verbal or written; however, it must be documented in the medical record.

Yes. Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost-sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical record, and includes informing them about: 

  • The availability of CCM services and applicable cost-sharing 
  • That only one practitioner can furnish and be paid for CCM services during a calendar month 
  • The right to stop CCM services at any time (effective at the end of the calendar month) 

Informed patient consent needs to be obtained only once prior to furnishing CCM, or if the patient chooses to change the practitioner who will furnish and bill CCM.

Care Plans

Comprehensive Care Plan

  • Creation, revision, and/or monitoring (as per code descriptors) of an electronic person-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues with particular focus on the chronic conditions being managed.
  • Must at least electronically capture care plan information and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the patient’s care.
  • A copy of the plan of care must be given to the patient and/or caregiver

CCM Documentation

No, as provided in the CY 2014 PFS final rule (78 FR 74424), a new consent is only required if the patient changes billing practitioners, in which case a new consent must be obtained and documented by the new billing practitioner prior to furnishing the service.

 

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