Details define requirements for chronic care management

Chronic care management (CCM) is a unique physician fee schedule service designed to pay separately for non-face-to-face care coordination services furnished to part B Medicare beneficiaries with multiple chronic conditions. It applies to practices and patients that are not included in alternative payment models. The code (99490) fills a long-awaited void in treating patients with multiple chronic conditions and was included in the Centers for Medicare and Medicaid Services' final Physician Fee Schedule rule for 2015.

CCM services are management and support services provided by clinical staff under the direction of a physician or other qualified health care professional to a patient residing at home or in a domiciliary, rest home, or assisted living facility. The physician or other qualified health care professional provides or oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs, and activities of daily living. Services typically include establishing, implementing, revising, or monitoring the care plan; coordinating the care of other professionals and agencies; and educating the patient or caregiver about the patient's condition, care plan, and prognosis.

A plan of care must be documented and shared with the patient and/or caregiver. It should be comprehensive, based on a physical, mental, cognitive, social, functional, and environmental assessment, and address all health problems. It typically includes but is not limited to the following elements: problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community and social services ordered, direction and coordination of the services of agencies and specialists unconnected to the practice, identification of the individuals responsible for each intervention, requirements for periodic review, and, when applicable, any revisions.

Physicians or qualified health care professionals treating patients with 2 or more chronic conditions could be eligible to bill the code. However, only 1 physician or qualified health care professional may report these services for a given patient in a given month.

There is no defined list of diagnosis codes that meet the requirements of CCM. Rather, what is required is that the chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline and that management requires a care plan.

Calculating staff time

A requirement of the CCM services code is at least 20 minutes of clinical staff time directed by a physician or physician time, if the physician performs the clinical staff function. This code deviates from the standard time-based coding in Current Procedural Technology nomenclature, which allows the reporting of a service once the mid-point of time is reached. CCM cannot be reported if fewer than 20 minutes are documented within a calendar month.

Any licensed clinician counts when calculating the clinical staff time required to meet the elements of the CCM codes. This includes a resident, nurse, nurse practitioner, physician assistant, or licensed medical aide. However, this does not include schedulers, coordinators, or receptionists, unless they are licensed clinical staff.

At this time, specific requirements have not been established for how the 20 minutes of time must be documented. However, it is in the health care professional's best interest to document the clock start and stop time, the content of the service (such as review of self-care data like glucose or peak flow monitoring, discussion of medication or treatment adherence, or patient education regarding management of therapies or side effects), and the date of the service.

Applying an electronic care plan

The electronic care plan must be accessible at all times to the clinicians within the practice, including those who are furnishing CCM outside of normal business hours. Clinicians “within the practice” means any clinician furnishing CCM services whose minutes count toward a given practice's time requirement for reporting the CCM billing code. Practices are not required to use a specific electronic technology. Practices may satisfy the care plan access requirement through (1) remote access to an EHR or portal, (2) web-based access to a care management application, (3) use of secure messaging, or (4) web-based access to a health information exchange service (HIE) that captures and maintains care plan information.

If you are considering using a third-party, web-based access to a care management application, make sure that the one you choose supports web-based access for external participants that allows reading and updating appropriate care plans.

Regular e-mail is not considered sufficiently secure for communication of individually identifiable health information. If external participants are capable of installing and using the Direct protocol, this may be a good communication option. 2014 certified EHR systems are required to support direct messaging. There are significant complexities involved in exchanging electronic certificates and navigating through different hubs. Expert assistance will be required for initial setup. This option will allow exchange of care plans as documents attached to e-mail messages. If the Direct protocol is not an option, there are third-party companies that provide secure e-mail services. This option will involve ongoing costs. However, setup and operation may be less difficult than using Direct protocols. Many EHRs allow for secure messaging with patients through their patient portals. Check with vendors to see whether a patient portal can become a way for outside participants to access and update care plans.

If there is a well-established HIE available, this may be a viable option. It is possible that the HIE specifically supports the exchange and management of care plans. If not, the HIE still may offer a simple method of exchange of care plans among participants, just as it would any other sort of clinical document. If either of these options exists, explore getting your external participants connected to the HIE.

Practices must always ensure that exchanges of health information comply with the Health Information Portability and Accountability Act. Check with EHR vendors to see if they have enabled a method for external participants to have limited access to relevant care plans without having to grant access privileges that exceed the minimum necessary to read and update specific care plans.

Other issues

An evaluation and management (E/M) visit may be billed at the same time as the CCM code, but any clinical staff time on a day when the physician reports an E/M service may not be counted toward the care management service code. E/M services may be reported separately by the same physician (or other qualified heath care professional) during the same calendar month.

CCM services may only be reported if the patient/caregiver has given consent. A requirement of the service is knowledge and recognition by the patient that the physician or qualified health care professional will perform CCM services on the patient's behalf. In the event of an audit, documentation of patient consent is crucial.

The informed agreement process need occur only once at the outset of furnishing the service, and it needs to be repeated only if the patient opts to change the practitioner who is delivering the services. The patient will be responsible for paying and the practice will be required to collect the 20% co-insurance and any applicable deductibles, unless the patient has separate supplemental coverage. You do not need to inform a beneficiary before each bill for CCM services is submitted.

ACP resources to help with CCM

To assist with appropriately capturing the required elements needed for CCM, ACP has created a CCM toolkit online. This new toolkit provides practices what they need to implement the new CCM codes, including background information for clinicians and staff, a step-by-step implementation guide, and a sample patient agreement.

The CCM program is still in its early days, and there are few experiences among users yet. As your practice attempts to fulfill this requirement with external participants, please let us know what works for you and what does not by e-mailing Brian Outland.