Chronic care management at last, and how to code for it

A final rule that updates payment policies and rates for services furnished under the Medicare Physician Fee Schedule makes it certain that Medicare will pay for chronic care management services (CCM). The key now is to understand how to bill and code to ensure reimbursement for the services that you've likely been doing all along, but not getting paid for.

Rather than creating a G-code, CMS adopted a new CPT code, 99490 (chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month) to describe CCM services that became effective Jan. 1, 2015. The policy outlined in the final rule emphasizes Medicare's interest in primary care by providing payment for non-face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions.

CCM includes aspects of chronic care such as regular development and revision of a plan of care, communication with other treating health professionals, and medication management. There are 2 essential elements for providing and billing CCM services: practice standards and scope of service.

Practice standards

Practice standards are one of the most critical components of the CCM policy. First, an office reporting CCM is required to use an electronic health record (EHR) that meets certification criteria that would qualify for the preceding Physician Fee Schedule payment year. This “CCM-certified technology” requires an EHR that satisfies either the 2011 or 2014 edition of the certification criteria for the EHR Incentive Programs and meets 2 core technology capabilities: structured recording of demographics, problems, medications, and medication allergies, and creation of summary care record.

Another requirement is that the office be able to electronically capture care plan information. The care plan information must be made available on a 24/7 basis to all practitioners within the practice who are furnishing CCM services and whose time counts toward the time requirement for the practice to bill the CCM code. (By “within the practice,” CMS means any practitioners doing CCM services whose minutes count toward a given practice's time requirement for reporting the CCM billing code.)

Additionally, the care plan information must be electronically shared (other than by fax) as appropriate with other clinicians who are furnishing care to the beneficiary. The billing clinician must develop and regularly update at least annually an electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental assessment of the beneficiary's needs.

According to CMS, the following elements should be typically included in the care plan:

• problem list; expected outcome and prognosis; and measurable treatment goals,
• symptom management and planned interventions, including all recommended preventive care services,
• community/social services to be accessed,
• plan for care coordination with other clinicians,
• medication management, including a list of current medications and allergies; reconciliation with review of adherence and potential interactions; oversight of patient self-management,
• responsible individual for each intervention, and
• requirements for periodic review/revision.

The plan should address all health issues, not just chronic conditions, and reflect the beneficiary's choices and values.

CMS also requires that clinicians document provisions of the care plan as required to the beneficiary in the EHR using CCM-certified technology. Specifically, the following must be shown in the beneficiary's record:

• documentation of the beneficiary's written consent and authorization in the EHR,
• provision of a care plan to the beneficiary, and
• communication to and from home and community-based clinicians regarding the patient's psychosocial needs and functional deficits.

Clinical summaries also must be formatted according to CCM-certified technology. However, as with care plan information, clinicians are not required to use a specific tool or service to exchange/transmit clinical summaries, as long as they are transmitted electronically (other than by fax). The clinician must be able to transmit the summary care record electronically for purposes of care coordination.

Scope of service

The scope-of-service requirements, which practices must meet in order to bill for this code, are an area about which ACP has expressed concern to CMS, provided feedback, and sought clarification. The Centers for Medicare and Medicaid Services outlined the following elements of the scope of service that are to be included in a 30-day period for CCM:

• continuity of care with a designated practitioner or member of the care team with whom the beneficiary is able to get successive routine appointments;
• access to care management services 24/7 (providing the beneficiary with a means to make timely contact with clinicians in the practice to address his or her urgent chronic care needs regardless of the time of day or day of the week);
• care management for chronic conditions, including systematic assessment of the beneficiary'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 beneficiary self-management of medications;
• creation of a patient-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; and sharing of the care plan as appropriate with other practitioners and clinicians;
• provision of a written or electronic copy of the care plan and documentation of its provision in the electronic medical record;
• management of care transitions between and among clinicians and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities; and
• coordination with home- and community-based clinical service clinicians.

Three more elements for scope of service relate to beneficiary consent:

• Inform the beneficiary of the availability of CCM services and obtain his or her written agreement to have the services provided, including authorization for the electronic communication of his or her medical information to other treating clinicians. Document in the beneficiary's medical record that all of the CCM services were explained and offered, and note the beneficiary's decision to accept or decline these services. Enhance opportunities for the beneficiary and any caregiver to communicate with the practitioner regarding the beneficiary's care not only through telephone access, but also through the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods;
• Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month) and the effect of a revocation of the agreement on CCM services; and
• Inform the beneficiary that only 1 practitioner can furnish and be paid for these services during a calendar month.

Clinicians who meet the CCM criteria include physicians (regardless of specialty), advanced practice nurses, physician assistants, clinical nurse specialists, and certified nurse midwives who are eligible to bill Medicare. Other nonphysician clinicians and limited-license practitioners such as clinical psychologists and social workers are not eligible to bill for CCM. It is also important to remember that CMS will pay only 1 claim for CCM per beneficiary per calendar month.

There are no prerequisites to billing CCM, although CMS strongly recommends that a clinician furnish an annual wellness visit or an initial preventive physical exam to the beneficiary. However, transitional care management, home health care, hospice care, and end-stage renal disease services are not eligible to be billed when CCM is provided. The clinician should bill for such services as an office visit or an immunization if the service is provided to the beneficiary in addition to CCM.

A beneficiary is eligible to receive CCM if he or she has been diagnosed with 2 or more chronic conditions expected to persist at least 12 months (or until death) that place him or her at significant risk of death, acute exacerbation/decompensation, or functional decline.

A clinician cannot bill for CCM unless and until the clinician secures the beneficiary's written consent. Specifically, the beneficiary must acknowledge in writing that the clinician has explained the following:

• the nature of CCM,
• how CCM may be accessed,
• that only 1 clinician at a time can furnish CCM for the beneficiary,
• that the beneficiary's health information will be shared with other clinicians for care coordination purposes,
• that the beneficiary may stop CCM at any time by revoking consent, effective at the end of the current calendar month, and
• that the beneficiary will be responsible for any associated co-payment or deductible.

A copy of the signed consent form must be maintained in the beneficiary's medical record. Once a beneficiary revokes his or her consent to receive CCM from a specific clinician, that clinician cannot bill for CCM after the current calendar month. The clinician may bill for CCM for the month in which the revocation is made, if the clinician has furnished at least 20 minutes of non-face-to-face care management services for the beneficiary.

ACP is creating tools to assist in the use of CCM. Please visit the Running a Practice website for access to more information and tools to help implement CCM codes in your practice.

Have you had success in implementing CCM in your practice? Contact Brian Outland with your best practices.