Chronic Care Management: New care coordination and revenue opportunities

February 11, 2015

Blog Post

Last month, Medicare began paying 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.

The CCM policies provide new opportunities to furnish coordinated care while finding new sources of revenue for services that previously did not generate reimbursement. The 2015 Medicare Physician Fee Schedule Final Rule recognizes a new CPT code (99490) for CCM and establishes an average national payment amount of $40.39 per month.

Satisfying and documenting compliance with the requirements for CCM reimbursement will present compliance hurdles and related challenges. The Centers for Medicare & Medicaid Services (CMS) has established the following requirements for CCM services:

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;
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);
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;
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
The practice must use a certified EHR and capture plan of care information electronically.

For more information on CCM, see our recent alert "Medicare to pay for chronic care management."

CMS will hold a National Provider Call on February 18, 2015, from 1:30 to 3:00 pm EST regarding requirements for billing CCM services. For information and registration, go to: http://www.eventsvc.com/blhtechnologies

Over the past 24 months, the U.S. Department of Health and Human Services Office for Civil Rights has brought notable enforcement efforts against several non-profit covered entities and business associates, resulting in instances of six and seven-figure penalties against providers across the county for incidents involving breaches of protected health information.

A new amendment to New York state law, which would have required all healthcare providers to obtain separate consents from patients for treatment and payment is on hold until further guidance is released, according to the New York Department of Health.

On November 1, 2024, the Centers for Medicare & Medicaid Services issued the Medicare Physician Fee Schedule 2025 final rule, which establishes new advanced primary care management billing codes that will expand opportunities for physician practices, federally qualified health centers, rural health clinics and other health care providers to get paid for services provided by clinical staff under the direction of a physician, nurse practitioner or physician assistant beginning January 1, 2025.

Chronic Care Management: New care coordination and revenue opportunities

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