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Commencing in January 2015, Medicare will pay qualified healthcare practitioners (namely, physicians, nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives) and their practice entities a chronic care management (CCM) monthly fee to coordinate care for Medicare beneficiaries who have multiple chronic conditions. This change expands Medicare payment policy to specifically allow for compensation for non-face-to-face management services. Medicare had previously accounted for such services as non-billable services incidental to an evaluation and management (E/M) visit.

Overview

The 2015 Medicare Physician Fee Schedule (MPFS) Final Rule recognizes a new Current Procedural Terminology (CPT) code (99490) for CCM and establishes an average national payment amount of $40.39 per month. The Centers for Medicare & Medicaid Services (CMS) has established the following criteria to bill for CCM services:

  1. The beneficiary must have at least two chronic conditions that (a) are expected to last at least 12 months or until death, and (b) create significant risk of death, acute exacerbation/decompensation, or functional decline;
  2. The practitioner must inform the beneficiary about the CCM services, obtain written consent, provide the beneficiary with a written or electronic copy of the care plan, and ensure that the beneficiary’s consent and receipt of the care plan are documented in the electronic health record (EHR);
  3. The practice must satisfy scope of service elements involving enhanced access, continuity of care, a plan of care, medication management, and communication with other healthcare professionals involved in treating the beneficiary;
  4. Clinical staff directed by a physician or other qualified practitioner must provide at least 20 minutes of CCM services for the beneficiary during the month; and
  5. The practice must use a certified EHR and capture plan of care information electronically.

Beneficiary Eligibility

Medicare beneficiaries with at least two “chronic conditions” are eligible for CCM services if the conditions are expected to continue at least 12 months, or until the death of the patient, and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Beyond these somewhat general references, CMS has not defined which specific conditions will qualify for CCM reimbursement, the level of severity required, or how multiple conditions may be viewed in combination. However, for separate applications, CMS has acknowledged the following as “chronic condition categories” in its Chronic Conditions Data Warehouse:

  • Acquired hypothyroidism
  • Acute myocardial infarction
  • Alzheimer's disease
  • Alzheimer's disease, related disorders, or senile dementia
  • Anemia
  • Asthma
  • Atrial fibrillation
  • Benign prostatic hyperplasia
  • Colorectal, endometrial, breast, lung and prostate cancers
  • Cataract
  • Chronic kidney disease
  • Chronic obstructive pulmonary disease
  • Depression
  • Diabetes
  • Glaucoma
  • Heart failure
  • Hip / pelvic fracture
  • Hyperlipidemia
  • Hypertension
  • Ischemic heart disease
  • Osteoporosis
  • Rheumatoid arthritis / osteoarthritis
  • Stroke / transient ischemic attack

Chronic Conditions Data Warehouse

In order to avoid duplicate payment, only a single CCM payment is allowed for services to a particular beneficiary, and CCM billing is not allowed for services to patients who:

  • Receive services that are billed as transitional care management, home healthcare supervision, hospice care supervision, or certain ESRD services; or
  • Are attributed to the billing practice under the Multi-payer Advanced Primary Care Practice Demonstration or the Comprehensive Primary Care Initiative.

Beneficiary consent

Prior to furnishing or billing for CCM services, the practitioner is required to (i) inform the beneficiary about the CCM services and the beneficiary’s responsibility to pay coinsurance (approximately $8 per month), (ii) discuss the services with the beneficiary, (iii) obtain the beneficiary’s written consent, and (iv) provide to the beneficiary a written or electronic copy of the care plan. These communications must be documented in the EHR. CMS recommends that the practitioner furnish an annual wellness visit or preventive physical exam, but this is not required. If a consent (or revocation of consent) is obtained from a representative of the beneficiary, the provider should confirm and document that the person has authority to act on behalf of the beneficiary.

Beneficiaries may revoke their consent at any time, either verbally or in writing, in which case the provider is required to record the revocation date in the beneficiary’s EHR and furnish the beneficiary with written confirmation that the practitioner will stop providing CCM services after the current month. At the time of consent, the practitioner is required to inform the beneficiary of the right to stop CCM services at any time and the effect of revocation.

Scope of CCM services

The following scope of service elements are required in order to qualify for CCM reimbursement:

  • Enhanced access. The provider must grant the patient and caregiver:
    • Access to healthcare providers in the practice on a 24/7 basis to address acute chronic care needs on a timely basis, and
    • Enhanced opportunities to communicate by telephone as well as secure messaging, Internet, or other asynchronous non-face-to-face methods.
  • Continuity of care. The provider must give continuity of care with a designated practitioner or member of the care team for successive routine appointments.
  • Care management. The provider must manage care for chronic conditions, including:
    • Systematic assessment of the patient’s medical, functional, and psychological needs,
    • System-based approaches to ensure timely receipt of recommended preventive care services,
    • Medication reconciliation,
    • Oversight of medication self-management, and
    • Development and updating (in consultation with the patient, caregiver, and other practitioners) of a written, patient-centered plan of care for all of the beneficiary’s health issues.
  • Transition management. The provider must manage “care transitions,” including:
    • Referrals to healthcare professionals,
    • Visits following emergency department visits and discharges from hospitals and skilled nursing facilities,
    • Communications through electronic exchange of a summary care record regarding the transitions, and
    • Availability of qualified personnel to deliver timely transitional care.
  • Coordination. The provider must coordinate care between home and community based clinical service providers to support the patient’s psychosocial needs and functional deficits, with the communications documented in the EHR.

20-minute minimum

Clinical staff members who are supervised by a physician, or other qualified practitioners must provide at least 20 minutes of CCM services for the beneficiary in order to bill under new CPT code 99490 for the month. CMS has stated its expectation that the 20 minutes of time would typically be provided by clinical staff members directed by the physician or other healthcare professional. When multiple clinical staff members spend overlapping time (such as being part of the same meeting), only the time of one staff member can be included.

The 2015 MPFS Final Rule made two policy revisions that allow greater flexibility for using clinical staff to satisfy the 20-minute per month minimum. CMS loosened the Medicare “incident to” supervision requirement to allow general supervision for CCM (rather than the more stringent direct supervision standard in place for most incident to services), so that services of clinical staff members can be counted toward the 20-minute minimum even if the practitioner is not present. In addition, CMS removed the direct employment requirement previously set forth in the 2014 MPFS Final Rule, so that clinical staff members can be retained on an independent contractor basis if direct employment doesn’t fit the business model.

EHR requirements

The provider is required to use certified EHR technology and provide an electronic care plan accessible to all providers within the practice and to care team members outside the practice.

For core elements (e.g., structured recording of demographics, problems, medications and medication allergies, as well as the creation of a structured clinical summary record), the provider will need to use an EHR system certified to satisfy the EHR incentive program certification criteria for the period ending on December 31 of the immediately preceding calendar year. For 2015, the proposed policy would have required use of EHR technology certified to the 2014 edition, but the EHR standard can now be satisfied for 2015 by using EHR technology that is certified to either the 2011 or 2014 editions. This level of certified EHR technology must be used to fulfill all CCM scope of service requirements that reference a health or medical record, including documentation that the care plan has been given to the beneficiary, communication with home and community providers, and beneficiary consent.

The 2015 Final Rule requires care plan information to be captured electronically and made available to all practitioners within the practice who furnish CCM services counting toward the monthly 20-minute reimbursement requirement. In addition, the care plan information must be shared electronically (other than via facsimile) with other practitioners and providers who furnish care to the beneficiary.

Implications and action steps

The CCM policies will provide new opportunities for medical practices to furnish coordinated care while finding new sources of revenue. Physicians in practice settings that are conducive to the CCM model may find that with careful structuring CCM can potentially improve the health of their patients as well as their bottom line.

In some practices, a substantial majority of the Medicare patients could be suffering from multiple chronic conditions and eligible for CCM. A November 27, 2014, article in the New England Journal of Medicine estimates that two-thirds of Medicare patients have qualifying chronic conditions. The actual number, however, is difficult to quantify in light of the limited guidance.

The CCM program has some of the tantalizing characteristics of “forbidden fruit.” On the one hand, the CCM revenue for a medical practice (or even a single physician) can potentially be substantial. On the other hand, in light of the financial temptations and the new conditions that need to be satisfied, the CCM concept appears susceptible to compliance challenges and accusations of fraud if not carefully monitored. CCM services are, therefore, likely to generate close scrutiny and a corresponding need to implement effective systems to address a morass of compliance concerns. Practitioners should be mindful of the potential for second-guessing from government auditors and qui tam whistleblowers if documentation fails to clearly show satisfaction of all required standards every month for which CCM claims are filed.

Providers who have an interest in furnishing CCM services for Medicare beneficiaries should review the CCM scope of services and related requirements, as well as their capabilities, infrastructure, and roster of patients to determine the feasibility of furnishing CCM services. Providing CCM services will require advance planning and investment, so it is important to allow sufficient lead time to engage and train appropriate personnel, develop infrastructure, implement policies and procedures, identify eligible beneficiaries, and take other steps to provide effective and compliant CCM services.

Open issues and concerns

The new CCM policies raise many important questions and details that await future guidance. For example:

  • How will “chronic conditions” be defined? In particular, what diseases will qualify, and will a particular level of severity be required in order to establish beneficiary eligibility? In the absence of clear standards, it may be difficult to proceed with confidence that determinations of patient eligibility for CCM will be respected.
  • How can a practitioner confirm that a beneficiary has not consented to receive CCM services from another practice?    
  • To what extent will the 20 percent copay deter beneficiaries from consenting to CCM services?
  • How can medical necessity be documented?
  • With 24/7 access, “enhanced” provider communications and other scope of service elements now “covered services” under CMS guidelines, how will this implicate hybrid fee-for-service concierge medical practices?
  • What qualifications are needed in order for practice personnel to qualify as “clinical staff” so that their services can be included for purposes of determining whether the 20-minute minimum is satisfied with respect to a particular beneficiary? How is “clinical staff” distinguished from other “auxiliary personnel” who may satisfy reimbursement requirements for other “incident to” services?
  • What does a practice need to document in order to show that the scope of services and 20-minute minimum standards are satisfied?
  • How will CMS and its administrative contractors determine whether to subject practices to additional audits or other scrutiny based on CCM billing patterns?
  • To what extent will private payors implement similar reimbursement policies, and how will the terms differ from the Medicare policies?

To protect themselves, physicians and other providers who desire to bill for CCM services will need to invest in technology, training, and related infrastructure capable of offering the enhanced services and documenting them. Failure to document satisfaction of all applicable requirements would be a recipe for potential audit and false claims exposure.

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