2017 chronic care management (ccm) program .new medicare payment for ccm beginning january 1, 2015,

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  • 2017 Chronic Care Management (CCM) Program

    REGULATORY UPDATES & HEALTH ENDEAVORS CCM PROGRAM

  • New Medicare Payment for CCM

    Beginning January 1, 2015, Medicare started paying for chronic care management, or CCM. As detailed

    below, CCM payments will reimburse practitioners for furnishing specified non-face-to-face services to

    qualified beneficiaries over a calendar month.

    Specifically, CMS adopted CPT99490 for Medicare CCM services, which is defined in the CPT Professional

    Codebook as follows: Chronic care management services, at least 20 minutes of clinical staff time directed

    by a physician or other qualified health care 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.

  • Face-to-Face Initiating VisitStart Initiation during an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE or Welcome to Medicare

    Visit), face-to-face E/M visit (Level 4 or 5 visit not required), for new patients or patients not seen within 1 year prior to thecommencement of chronic care management (CCM) services.

    The face-to-face visit is NOT a component of the CCM service, and thus may be billed separately.

    G0506 Add-on Code. Comprehensive assessment of and care planning by the physician or other qualified health careprofessional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service. This add-on code is to be listed separately in addition to the primary service and billed separately from monthlycare management services. The projected payment rate for G0506 is $63.68 (non-facility) and $46.15 (facility).

    E/M Visit

    G0506

    Add-on Code

    OR G0505 Add-on

    Code AND Prolonged

    Service Codes

    Total Billing Initiating

    Visit

  • G0506 Additional work of the billing practitioner in personally performing a face-to-face assessment

    Add-On Code

    Acknowledging complaints that the time spent developing the CCM-required care plan currently is notreimbursed, CMS proposes to pay physicians for care plan development under a new code, G0506. The agencyproposed the following description for this code:

    Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of a face-to-face service.

    This add-on code is to be listed separately in addition to the primary service and billed separately from monthly care management services. The projected payment rate for G0506 is $63.68 (non-facility) and $46.15 (facility).

    E/M Visit

    G0506

    Add-on Code

    OR G0505 Add-on

    Code AND Prolonged

    Service Codes

    Total Billing Initiating

    Visit

  • Prolonged E/M Service CodesProlonged

    CCM and Complex CCM reimburse providers for clinical staff time spent providing care management services, not time spentby physicians. Recognizing the additional resource costs involved in spending an extraordinary amount of time outside theoffice visit caring for an individual patients needs, CMS proposes to make payment under two codes:

    CPT 99358 Prolonged E/M service before and/or after direct patient care, first hour

    CPT 99359 Prolonged E/M service before and/or after direct patient care, each additional 30 minutes (listed separately inaddition to CPT 99358)

    In discussing these services, CMS warns the time counted for these codes must be beyond the usual service time for theprimary or companion E/M code that is also billed; no time can be counted more than once toward the provision of CPT99358, 99359, and any other service reimbursable under the Medicare Physician Fee Schedule. The projected payment rate for99358 is $113.41 (facility and non-facility); for 99359, it is $54.38 (facility and non-facility).

    E/M Visit

    G0506

    Add-on Code

    OR G0505 Add-on

    Code AND Prolonged

    Service Codes

    Total Billing Initiating

    Visit

  • Care Plan Development Add-

    on Code G0506

    Payment to physicians for care plan

    development under new code, G0506.

    Comprehensive assessment of and care planning by the physician or other qualified health care

    professional for patients requiring CCM services, including assessment during the provision of a

    face-to-face service.

    The projected payment rate is $63.68 (non-facility) and $46.15 (facility)

    Same or different day

    G0505 companion code plus Non-Face-to-Face Prolonged

    E/M Services 99358 and 99359

    Cognition and functional assessment

    Extraordinary amount of time outside the office visit caring

    for an individual patients needs.

    99358 prolonged E/M service before and/or after direct patient

    care, 60 minutes

    99359 prolonged E/M service before and/or after direct patient care, each additional 30 minutes

    after 99358

    Projected payment rate for 99358 is $113.41 (facility and non-facility

    and for 99539 is $54.38 (facility and non-facility)

    Same or different day

  • E/M Visit

    G0506

    Add-on Code

    $63.68

    Total Billing Initiating Visit

    E/M Visit

    G0505 Add-on Code

    $238.30

    99358 60 minutes

    $113.41

    99359 each

    additional 30 minutes

    $54.38

    Total Billing Initiating

    Visit

    Same Day or Different Day

  • Confirm Patient CCM Eligible Next

    2+ Chronic Conditions expected to last at least 12 months (oruntil death that place the patient at significant risk of death,acute exacerbation/decompensation, or functional decline.

    CMS has not mandated a definitive list of chronic conditions for purposes of CCM. Health Endeavors generally uses https://www.ccwdata.org/web/guest/home

    https://www.ccwdata.org/web/guest/home

  • Verbal Consent DocumentedNext Inform the beneficiary of the availability of CCM services; that only one practitioner can furnish

    and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month)

    Document in the beneficiarys medical record that the required information was explained and whether the beneficiary accepted or declined the services.

    Co-pay DiscussionNext Verify if Medicare Supplement payment available

    If no supplement, then monthly co-pay collection

    Waiver of Co-pay for indigent patients

  • Structured Recording of Patient Information Using Certified EHR Technology

    Structured EHR

    Technology Structured recording of demographics, problems, medications and

    medication allergies using certified EHR technology.

    A full list of problems, medications and medication allergies in theEHR must inform the care plan, care coordination and ongoingclinical care

  • 24/7 Access & Continuity of Care

    24/7 Access

    Provide 24/7 access to physicians or other qualified health care professionals or clinicalstaff including providing patients/caregivers with a means to make contact with health careprofessionals in the practice to address urgent needs regardless of the time of day or dayof week; e.g. after hours service, hospital emergency department.

    Continuity of care with a designated member of the care team with whom the beneficiaryis able to schedule successive routine appointments.

  • Initial Care Plan developed by billing practitioner

    Initial Care Plan

    Comprehensive Care Plan

    Creation, revision and/or monitoring (as per code descriptors) of an electronic patient-centered care plan based on aphysical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources andsupports; a comprehensive care plan for all health issues.

    Must at least electronically capture care plan information, and make this information available timely within andoutside the billing practice as appropriate. Share care plan information electronically (can include fax) and timelywithin and outside the billing practice to individuals involved in the beneficiarys care.

    A copy of the plan of care (in any form) must be given to the patient and/or caregiver.

  • Request Patient Case Management Services

    Request Staffing

  • 20 minutes99490 Chronic care management (CCM) services under CPT code 99490 (Chronic care management services, at

    least 20 minutes of clinical staff time directed by a physician or other qualified health professional, percalendar month, with the following required elements:

    Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of thepatient;

    Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, orfunctional decline;

    Comprehensive care plan established, implemented, revised, or monitored.

  • 60 minutes

    99487

    Complex CCM

    CPT code 99487Complex 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 thepatient;

    Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, orfunctional decline;

    Establishment or substantial re

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