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 patient’s 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 patient’s 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
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 beneficiary’s 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 beneficiary’s 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 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 thepatient;
• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, orfunctional 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 health care professional, percalendar month.
Each additional 30 minutes after initial 60 minutes
99489
Complex CCM
•CPT code 99489—Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).
RHC SupervisionRHC
• After considering the comments, we are finalizing thispolicy to revise §405.2413(a)(5) and §405.2415(a)(5)to state that services and supplies furnished incidentto CCM and TCM services can be furnished undergeneral supervision of a RHC or FQHC practitioner.
CPC+ also excluded from CCM program as program has its own components of CCM.
Operational Workflow
#1 Schedule face-to-face initiating visit. Check for 2+ chronic
conditions and identify chart as CCM Eligible with sticker or
electronic methodology. Include Health Endeavors CCM Patient
Brochure in chart for visit.
#2 At face-to-face initiating visit obtain patient verbal consent and
conduct copay discussion using Health Endeavors CCM Patient
Brochure to guide the conversation. Note the verbal consent in patient
chart.
#3 Conduct and bill face-to-face initiating E/M visit and Add-On or
Prolonged Service Codes (depending on time spend with patient).
#4 Create plan of care in EHR. Health Endeavors must have access
to EHR for each CCM patient.
#5 Request Health Endeavors CCM Services via Health Endeavors
Portal. Must complete all mandatory fields.
#6 Health Endeavors verify no other provider billing 99490, TCM or
other conflicting codes using claims data.
#7 Health Endeavors commence CCM Basic (20 minutes) and
Complex Services (60 minutes plus 30 minutes).
#8 Health Endeavors staff onsite in clinic or offsite call centers located
in Omaha, NE and Phoenix, AZ
Must have at least 100 consents and 300 total potential eligible patients
for Health Endeavors to staff program.
#9 For clinic staff access to Health Endeavors events and reporting
tools setup patient match API/Single Sign-On.
Patient brochure to assist in
provider-patient discussion
about CCM enrollment.
Conduct Monthly Assessment
• Identify patient needs on a monthly basis for Referrals/Orders, Appointments and Prescription Renewal using Care Coordination Patient Needs Assessment Template (Monthly Assessment).
• Health Endeavors communicate Monthly Assessment to clinic nurse manager via fax or secure email on a daily or weekly basis. Alternative – clinic provide point of contact (real-time) to set appointments, provider referrals/orders and prescription renewal.
• Health Endeavors may be granted access to schedule appointments in clinic scheduling system (optional).
Patient Phone Intervention with
clinical staff
• Review Monthly Assessment with Patient. Complete assigned template for month; e.g. Fall Screening, medication reconciliation, immunization reminder, etc.
• 3 attempts made each month. Voice message left with #800 return number.
• Call made on behalf of Assigned Provider.
• Area Code masking to local area code available upon request.
Patient Empowerment Portal
(MACRA Compliance)
• Online Chat with clinical staff
• Monthly Things to Complete - Online Screenings (Customizable Templates)
• Things to Complete Email/Text Message reminders
• Patient Disease-Specific Education with interactive quizzes
• Measurable Goal Setting Templates (Intervention Templates)
• Continuity of Care Record/Document transfer from EHR to patient (Clinical Summary)
Benefits of
CCM 99490
Patient Case Management
Quality Measure Completion
ACO Shared Savings
Revenue Generation
Improve Patient Experience
Improve Patient Health
Value-Based Medicine
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