cms chronic care management (ccm) billing · 2016. 5. 11. · cms chronic care management (ccm)...

M A R Y L A N D L E A R N I N G C O L L A B O R A T I V E

A P R I L 1 4 , 2 0 1 6

J O S E P H K . W E I D N E R , J R . M D , F A A F P

S T O N E R U N F A M I L Y M E D I C I N E

CMS Chronic Care Management (CCM) Billing


Topics covered

• Service Requirements • Billing Requirements • Implementation • Stone Run’s Workflow and Billing Processes • Stone Run’s Experience • Marketing/ Promotion to Patients

MLC 4/14/2016 Joseph K. Weidner, Jr. MD, FAAFP Stone Run Family Medicine


Service Requirements


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf


Who can perform CCM ?


Bill under:

Physicians

Certified Nurse Midwives

Clinical Nurse Specialists

Nurse Practitioners

Physician Assistants

Services provided by all the above and clinical staff


Who are Clinical Staff?


CPT defines a clinical staff member as "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."


Who are Clinical Staff? - ACP


Clinical staff – Licensed clinical staff members (including APRN, PA, RN, LSCSW, LPN, clinical pharmacists, and “medical technical assistants” or CMAs) who are directly employed by the clinician (or the clinician’s practice) or a contracted third party and whose CCM services are generally supervised by the clinician, whether provided during or after hours. Thus the “incident to” rules do not necessarily require that the clinician be on the premises providing direct supervision.


Billing requirements


Initiated at a visit. (E/M, AWV, IPPE)

Use and billing through a certified EHR that satisfies the 2011 or 2014 edition of the certification criteria for the EHR Incentive Program

Maintain an comprehensive care plan (documented)

Ensure patient electronic access to care

Facilitate transitions of care

Coordinate care – 20 minutes contact-based (documented)


Billing requirements – what counts


Coordinate care – 20 minutes contact-based (documented)

Phone/ Electronic communication

With patient or individual patient related

In-person visits segregated from other encounters Use modifier -25 if billed on the same day

Not

Clerical/scheduling staff

Time otherwise spent during a visit

Generating reports

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1516.pdf


Billing requirements


• CPT code 99490

• Written consent (documented) obtained at visit

• Bill only through one clinician per month

• Copayments/Deductibles do apply.

Supplemental insurers that have not paid SRFM:

BCBS Federal (FEP)

Tricare for Life


Implementation – (ACP2015) Step 1: Identify the patients


EHR generated report:

consider those with 2 or more chronic conditions

review by clinicians

consider focusing on a few problems

Problems: Not predictive of need, death, or decline

Use report to generate who needs a consent form


Implementation (ACP 2015) Step 2: Designate personnel and process


Designate clinician

Clinical staff providing services

Appointment/Encounter codes – schedule

Non-clinical staff to assist with enrollment/consents

Monthly schedule of calls

Invitation to patient – explain above as well as billing

Review participation agreement (in person or via phone)

Record consent in chart https://www.acponline.org/system/files/documents/running_practice/payment_coding/medicare/chronic_care_management_toolkit.pdf


Implementation (Stone Run Family Medicine) Step 2: Designate personnel and process


Designate clinician – preferred provider

Clinical staff providing services

Appointment/Encounter codes – schedule

Non-clinical staff to assist with enrollment/consents

Monthly schedule of calls Encounter notification/point of care driven

Invitation to patient – explain above as well as billing

Review participation agreement (in person or via phone)

Record consent in chart




Preferred provider already selected in EHR Care managers (LPN/CMA) provide services Encounter type – Care Management Non-clinical staff identifies Medicare patients without consent Front desk staff run EHR generated report at start of every day

indicating which Medicare patients in schedule require a CCM agreement to be signed. Paperclips it to routing slip.

Rooming nurse explains to patient, leaves in room with patient to read and sign, provider clarifies and answer questions.

Consent paper clipped to routing slip – check out staff provide copy for patient at time they check out.

Consent scanned into chart


Implementation ACP – 2015 next steps


Create a comprehensive care plan

Provide patient a care plan

Document the time spent

Termination from program


Billing processes – Stone Run FM


Care Managers collect charges Sends charges through EMR clinical module to billing

Also keeps clipboard of patients

Billing reviews end of month. Reconciles with patients on clipboard, notes how long they have time spent.

Billing reconciles with: Transition Care Management (TCM) – CPT 99495 and 99496

Home Healthcare Supervision – HCPCS G0181

Hospice Care Supervision – HCPCS G9182

Certain ESRD services – CPT 90951-90970


Patient demographics – Stone Run FM


Medicare patients n=719 Billed 99490 n=182


SRFM monthly totals submitted


Average Payment Received

$41.69


Number of times patients billed



Marketing/ Promotion How to get consent from a patient


cms chronic care management (ccm) billing · 2016. 5. 11. · cms chronic care management (ccm)...

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