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Chronic Care Management FAQ Sheet

Chronic-Care-Management-FAQ-Sheet

1- What is Medicare’s Chronic Care Management Service?

Chronic Care Management (CCM) is defined as 20 minutes of non-face-to-face services provided by the physician or clinical staff to Medicare beneficiaries who have multiple (two or more), significant chronic conditions.

Examples of chronic conditions include, but not limited to:

    • Alzheimer’s Disease and Related Dementia
    • Arthritis (Osteoarthritis and Rheumatoid)
    • Asthma
    • Atrial Fibrillation
    • Autism Spectrum Disorders
    • Cancer (Breast, Colorectal, Lung, and Prostate)
    • Chronic Kidney Disease
    • Chronic Obstructive Pulmonary Disease
    • Depression
    • Schizophrenia and Other Psychotic Disorders
    • Heart Failure
    • Hepatitis (Chronic Viral B & C)
    • HIV/AIDS
    • Hyperlipidemia (High cholesterol)
    • Hypertension (High blood pressure)
    • Ischemic Heart Disease
    • Osteoporosis
    • Diabetes
    • Stroke

 2- Who is eligible to receive CCM services under Medicare?

According to the Centers for Medicare & Medicaid Services (CMS), CCM is for “patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”

3- Are CCM codes available to “dual eligible” patients (i.e., Medicare beneficiaries who are also eligible for Medicaid)?

Yes

4- Does CMS have a specified list of chronic conditions that meet this definition?

No, CMS has not specified or otherwise limited the eligible chronic conditions that meet this definition. CMS does have a databank regarding chronic conditions (http://www.ccwdata.org) that you can use as a starting point. However, this databank is neither an exhaustive nor definitive list. As long as you clearly communicate within the care plan that the chronic conditions you are treating post a significant risk of death, acute exacerbation or decompensation, or functional decline and will last the expected length of time, the requirement is satisfied.

5- How does CMS define the scope of CCM services?

CMS has established eight elements that it uses to define the current scope of CCM services:

1-  Access to care management services 24-hours-a-day, 7-days-a-week, which means providing patients with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.

2-  Continuity of care with a designated provider or member of the care team with whom the patient is able to get successive routine appointments.

3-  Care management for chronic conditions including:

      • Systematic assessment of patient’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,
      • Oversight of patient self-management of medications.

4-  Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.

5-  Management of care transitions between and among health care providers and settings, including the following:

      • Referrals to other clinicians,
      • Follow-up after a patient visit to an emergency department,
      • Follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.

6-  Coordination with home and community based clinical service providers as appropriate to support a patient’s psychosocial needs and functional deficits.

7- Enhanced opportunities for a patient and any relevant caregiver to communicate with the provider regarding the patient’s care through not only telephone access but also the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods.

8- Use of certified electronic health record (EHR) or other health information technology or health information exchange platform that includes an electronic care plan accessible to all providers within the practice, including those who are furnishing care outside of normal business

6- Who can provide services after the care plan has been generated?

The definition states that “clinical staff” must provide the 20 minutes to qualify. “Clinical staff,” as defined by CPT, “is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.” If the physician or other qualified health care professional (e.g. nurse practitioner or physician assistant) supplies the time, that time may also count toward the 20 minutes.

7- Can CCM services be subcontracted out to a case management company? What if the clinical staff employed by the case management company are located outside of the United States?

A billing physician (or other appropriate practitioner) may arrange to have CCM services provided by clinical staff external to the practice (for example, by a case management company) if all of the “incident to” and other rules for billing CCM to the PFS are met. Because there is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9), CCM services cannot be billed if they are provided to patients or by individuals located outside of the United States.

8- What is CPT 99490?

Chronic Care Management Services, takes at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored

9- Every time we speak to the patient on the phone during the month, does that count toward the 20-minute time threshold?

If the phone conversation is between the patient and a clinical staff person and if the conversation addresses management of the patient’s chronic conditions, then you may count that time toward the 20-minute threshold required to bill 99490.

10- How much does Medicare allow for this service?

The Medicare allowance will vary geographically. However, the geographically unadjusted amount is approximately $42 per month per eligible patient.

11- What are the new complex CCM codes?

CPT 99487 – Complex Chronic Care Management Services, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Establishment or substantial revision of a comprehensive care plan
  • Moderate or high complexity medical decision making
  • 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month

CPT 99489 – Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

12- How do physicians get paid for CCM services?

Mostly primary care physicians are billed for CCM services and in some cases, specialists involved in care are paid. But only 1 practitioner can be billed per patient per calendar month for either complex or noncomplex code.

13- Is billing for CCM services limited to primary care physicians?

No. While CMS expects the CCM code to be billed most frequently by primary care physicians, specialists who meet the requirements may also bill for these services. Nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives can also furnish the full range of these services under their Medicare benefit, to the extent permitted by applicable limits on their state scope of practice.

14- Can you give examples of what types of activities would fall under this code?

The following activities would be covered:

  • Phone calls and emails to/from the patient
  • Time spent making referrals to other care givers (does not include time faxing)
  • Prescription management (pharmacy phone time, counseling the patient, etc.)
  • Conversations with caregivers

15- What do I need from the patient before I bill the service?

CMS requires you to:

  • Inform the patient about the availability of CCM services from the provider and obtain his or her written agreement to have the services furnished, including authorization for electronic communication of the patient’s medical information with other treating providers as part of care coordination.
  • Document in the patient’s medical record that all of the CCM services were explained and offered to the patient, and note the patient’s decision to accept or decline these services.
  • Inform the patient of the right to stop CCM services at any time (effective at the end of a calendar month) and the effect of a revocation of the agreement on CCM services.
  • Inform the patient that only one provider can furnish and be paid for these services during a calendar month.

16- What is the best way to keep track of chronic care minutes?

Care providers generally keep track on the service time. A tracking software can be used to track every minute spent on care and documentation is done for reimbursement purpose. Based on the service offerings, time will be tracked for every interaction made with the patient on a monthly basis.

17- How to start Chronic Care Management to patients?

Patients with multiple chronic conditions first need to enroll for CCM care service. Effective January 1, 2017, enrollment of new patients can be done remotely via telephone by staff external to the practice (for example, by a case management company) if all of the “incident to” and other rules for billing CCM to the PFS are met.

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