On October 31, 2014, the Centers for Medicare & Medicaid Services (CMS) issued the 2015 Medicare Physician Fee Schedule (MPFS) Final Rule, which establishes payment levels and policy changes for Medicare Part B services. These changes include new reimbursement conditions for chronic care management (CCM) services.
Commencing in January 2015, Medicare will pay physicians, advanced practice registered nurses, physician assistants, clinical nurse specialists and certified nurse midwives a CCM flat (per patient) monthly fee to coordinate care for Medicare beneficiaries who have multiple chronic conditions. This new policy was established in the 2014 MPFS Final Rule and will expand Medicare payment policy to include non-face-to-face management services that have previously not been reimbursed. For more on CCM under the 2014 Final Rule, see our August 26, 2014 Alert. The 2015 Final Rule refines the CCM policy by adding new details and making
several revisions to the policy. In particular:
- The monthly CCM payment will be reduced slightly, from $41.92 (as proposed in July 2014) to $40.39 per patient.
- A number of commenters expressed concern that the beneficiary coinsurance amount (approximately $8 per month) will deter
beneficiaries from receiving CCM and so requested that CMS designate CCM as a preventive service exempt from beneficiary
cost sharing. CMS, however, determined that it does not have authority to add CCM as a preventive service and exempt CCM from coinsurance. CMS noted that providers are required to explain to beneficiaries their cost-sharing obligation and obtain prior consent.
- CCM will be billed under a new CPT code, 99490.
- For ease of administration, the service period will be changed from 30 days to the calendar month.
- The “incident to” supervision standard for CCM as well as transitional care management will be loosened to allow general
supervision (rather than the more stringent direct supervision standard typically in place for “incident to” services), so that services of clinical staff members can be counted toward the 20 minute per month minimum even if the physician is not present. Under the 2014 MPFS Final Rule, general supervision would have satisfied the supervision requirements for “incident to” CCM
services only when the CCM services are furnished outside of normal business hours by direct employees.
- 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) , a practice will need to use an electronic health record (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 of certification criteria, but the final policy can now be satisfied for 2015 by using EHR technology that is certified to either the 2011 or 2014 criteria. In addition, this level of certified technology must be used to fulfill all CCM scope of service requirements that reference a health or medical record.
- 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 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.
- A practice will be prohibited from billing under CCM codes for services furnished to beneficiaries who are attributed to the practice under the Multi-payer Advanced Primary Care Practice Demonstration or the Comprehensive Primary Care Initiative, as CMS views this as “duplicative” billing. The CCM policy already provides that CCM billing is not allowed for services to patients who receive services that are billed under CPT or HCPCS codes for transitional care management services, home health care supervision, hospice care supervision or certain ESRD services.
The 2015 Medicare Physician Fee Schedule Final Rule is available here, and is scheduled for publication in the Federal Register on November 13, 2014. Click here to see the CMS Fact Sheet summarizing various provisions of the Final Rule.