Medicare Update:Chronic Care Management

William C. Thornbury, Jr., MD, FAAFP

Conflict of Interest Disclosure

Disclose ownership in Jobathco Enterprises, Inc.Jobathco accounts for expenditures within medical technology.

William C. Thornbury, Jr., MD, FAAFP

Disclaimer

Dr. Thornbury is not, and does not intent to imply, that he is a certified medical coder or coding specialist. All details, herein, are for educational and informational purposes only. Before

applying any specific information or principles to one’s medical practice, review by a compliance office and due diligence is strictly mandated and fully rests upon the attendee.

William C. Thornbury, Jr., MD, FAAFP

Learning Objectives:

• Understand rationale behind the CMS design for provider fee service supporting Chronic Care Management.

• Understand CMS criteria for billing and reporting of Chronic Care Management services.

• Understand how Transitional Care Management differs from Chronic Care Management.

• Identify resources to help establish and provide Chronic Care Management services.

What is Chronic Care Management?

• CCM is a unique provider fee schedule. Designed to separately compensate for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.

• The intangibles of quality patient care. Comorbid patients exhaust 75% of the U.S. health dollar. They commonly require extended office support—well beyond the 25 minute encounter. CCM presents the means to account for this clinical and bureaucratic burden typically borne by the primary care provider.

• New CPT codes established. On January 1, 2015, CMS established CPT coding to acknowledge CCM allowing provider billing (and auditing) for such services.

Why is CCM Important?

• CMS recognizes the importance of primary care medicine. Value to the management of beneficiaries with complex underlying illnesses.

• CCM is a unique provider fee schedule. Designed to separately compensate for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.

• Shifting reimbursement models.

CCM represents, arguably, the most important broadly applicable change CMS has made to primary care payment to date. “Will allow provider to develop skill sets critical for population management and value-based reimbursement.”

So What?Today

• Modest 0.61RVU = $42.60 monthly.• Benjamin Franklin Says: • 4 pts/day X 4.5 day/wk X 50 wk X $42/mo = $ 37,500/yr

So What?Today

• Modest 0.61RVU = $42.60 monthly.• Benjamin Franklin Says: • 4 pts/day X 4.5 day/wk X 50 wk X $42/mo = $ 37,500/yr• 20 pts/day => $150,000/yr

So What?

Tomorrow• Proposed legislation to repeal the SGR: “…instituting payment increases of 0.5% for five years while Medicare transitions doctors to a new system that emphasizes quality care over volume of care.” Receive at least 25% of Medicare payment from “Alternative Models” by 2019-2020. McClatchy Washington Bureau March 19, 2015

So What?Today

• Modest 0.61RVU = $42.39 monthly.• Benjamin Franklin Says: • 4 pts/day X 4.5 day/wk X 50 wk X $42/mo = $ 37,500/yr• 20 pts/day => $150,000/yr

Tomorrow• Proposed legislation to repeal the SGR: “…instituting payment increases of 0.5% for five years while Medicare transitions doctors to a new system that emphasizes quality care over volume of care.” Receive at least 25% of Medicare payment from “Alternative Models” by 2019-2020. McClatchy Washington Bureau March 19, 2015

Chronic Care ManagementProvider Eligibility

• Physicians (regardless of specialty), APRN’s, PA’s, clinical nurse specialists, and certified nurse midwives (or the provider assigned), are eligible to bill Medicare for CCM.

• Other non-physician practitioners and limited-license practitioners (e.g., clinical psychologists, social workers) are not eligible.

• CMS will only pay one claim per beneficiary per calendar month.

Chronic Care ManagementPatient Eligibility

• Patients require:i. 2 or more chronic conditionsii. Expected to last 12 months, or until patient deathiii. Place the patient at significant risk of death, acute

exacerbation/decompensation, or functional decline

• Patient/Designate must agree and give written consent

Chronic Care Management 3 Global Requirements

A. Secure beneficiary’s written consent.

B. Five specified capabilities.i. Use a 2011/2014 certified EHR for specified purposes: (See Final Rule p.

474.)

ii. Maintain an electronic care planiii. Ensure beneficiary access to careiv. Facilitate transitions of carev. Coordinate care

C. 20+ Minutes of non-face-to-face care management servicesi. May be performed by licensed clinical staff under supervision

ii. APRNs, PAs, RNs, LSCSWs, LPNs, and CNA’s iii. Encounter time may not be rounded up

A. Patient Consent

• Beneficiary must be informed of the availability of CCM services.

Explain:• What the nature of CCM services are & how they will affect their care;• That services are not for face-to-face time with care team;• How services are accessed;• That only one provider at a time may furnish CCM services;• How their information may be shared among team members;• How cost-sharing (copay/deductible) applies to them;• The beneficiary may stop CCM at any time.

Then:• Obtain their written agreement to have services provided— including

authorization for electronic communication of the medical information with other treating providers.

A. Patient ConsentDocumentation

• Document the explanation of CCM in the patient’s medical record.• Note their decision to accept or decline the services.• Maintain a copy of the signed consent.• Consent only needs to be obtained once at initiation of services.• Consent must be repeated if patient changes providers.

A. Patient ConsentRevocation

• Patient has the ability to stop CCM services at any time.

• Provider may bill for CCM services during the month in which the revocation was made— if 20+ minutes of care management services was documented.

• No standard method to revoke.

B. Five Specified Capabilities1. CCM Certified EHR Technology

• “Meaningful Use” EHR not required.

• CCM (2011/2014) certified technology is.

• Must Record:

i. Demographicsii. Problem Listsiii. Medicationsiv. Allergiesv. Transmit Summary of Care Recordvi. Consent of Beneficiaryvii. Provide Care Plan to Beneficiaryviii. Communicate Care Coordination

B. Five Specified Capabilities2. Patient-Centered Care Plan Management

• “A plan of care is based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports.”

• Required:

• Systematic assessment of pt. medical, functional, and psychosocial needs.• List of current providers involved in the patient’s care• Assessment of functional status of the chronic health conditions• Assessment of cognitive/mental health conditions that could impair self-care• Assessment of preventive health needs• Be congruent with patient choices and values• Address all health needs, not just chronic disease• Update at least annually• Stored “electronically”

B. Five Specified Capabilities2. Care Plan Document

• CMS has not specially required defined elements in the care plan; however, it has identified items typically included:

• Problem list• Measureable treatment goals, outcomes & prognosis• Symptom management & planned interventions• All recommended preventive care services• Community/Social services to be accessed• Plan of care coordination with other providers• Responsible individual for each intervention• Oversight: patient self-management of medications• Medication reconciliation and management• Med list, drug allergies, review of adherence & potential interactions• Requirement for periodic review & revision

B. Five Specified Capabilities2. Care Plan Coordination & Communication

• CMS requires the provider to “use some form of electronic technology tool or services in fulfilling the care plan element”.

• Recognition of the limited capabilities of EHR’s/vendors.• Encourage providers to “use a wide range of tool/services beyond

EHR technology now available in the market to support electronic care planning”.

B. Five Specified Capabilities3. Access to Care

• Patient/Caregiver must have access to care management services.

• Established for acute and urgent needs.

• 24 hours a day, 7 days a week provider access.

• “Tom Sawyer provision”

B. Five Specified Capabilities3. Continuity of Care

• The patient must be able to obtain successive routine appointments with a designated provider/care team member.

B. Five Specified Capabilities3. Enhanced Communication

• Provide enhanced opportunities for beneficiary—provider communication.

• Should include:i. Telephone/Smartphone ii. SMS/Secure Messagingiii. Internet/ Web-based accessiv. Telemedicinev. mHealthvi. “and other asynchronous or non-face-to-face methods”

B. Five Specified Capabilities4. Transition of Care

• Afford patient follow-up with their provider after an ED visit.

• Afford follow-up after a hospital, skilled nursing facility, or other health care facility discharge.

• Provide post-discharge transitional care management (TCM). Note: Provider may not bill TCM & CCM during same month.

• Coordinate referrals to other clinicians.

• Share information electronically with other providers.

B. Five Specified Capabilities4. Sharing Electronic Information

• Communicate relevant patient information (summary/record) through electronic exchange is required upon care transitions.

• CCM information must be available on a 24/7 basis to all providers within the practice who are furnishing care services whose time counts toward the requirement for billing.

• Information must also be shared electronically as appropriate with other providers who are providing care to the beneficiary.

• Faxing is not allowed at this time for communication of information.

B. Five Specified Capabilities5. Care Coordination

• Provider must coordinate with home & community-based clinical service providers.

• Ensure appropriate support of a patient’s psychosocial needs and functional deficits are addressed:i. Home Health ii. Outpatient Therapies (PT/OT/ST)iii. Durable Medical Equipment coordinationiv. Transportation Servicesv. Nutrition Servicesvi. Hospice

• Provider communication with these services must be documented in “CCM certified technology”.

• Care team and family/caregiver must have electronic access.

C. 20+ Minutes of Non-Face-to-Face ServicesCare Management

• Services require 20+minutes non-face-to-face communication in a given calendar month

• May be fulfilled by licensed clinical staff under supervision.

• Examplesi. Performing medication reconciliation/overseeing the

beneficiary’s self- management of medications. ii. Ensuring receipt of recommended preventive services. iii. Monitoring the beneficiary’s condition: (physical/mental/social) iv. Address questions from patient/family/guardian/caregiver.v. Provide education to patient/caregiver.vi. Identify and arrange for community resources.vii. Communicate with home health agencies and other community

service providers utilized by the beneficiary.

C. 20+ Minutes of Non-Face-to-Face ServicesSupervision

• Communication by licensed staff:

• General Supervision is all that is required.i. Provider available by phone.ii. Available provider does NOT have to be same as CCM provider.iii. May contract-out services to 3rd party.iv. “Subscription services” could include after-hours availability.

C. 20+ Minutes of Non-Face-to-Face ServicesDocumentation

• CMS does not list explicit documentation requirements.• Compliance for audit of services may wish to include:

i. Date & amount of time (start/stop times) for servicesii. Clinical staff & credential furnishing servicesiii. Brief description of services

• Time providing services on multiple days in a calendar month may all be applied toward the CPT requirement.

• Time may not be carried to another month, nor “rounded up”.• Time spent while a patient is within an inpatient facility is not counted.• Services provided same day as an E&M code should not be counted.

• Providers that engage in remote monitoring of patient physiologic data may count time spend reviewing the reported data (not the time the patient spent wearing the monitoring device).

C. 20+ Minutes of Non-Face-to-Face ServicesDocumentation

• Example: i. Time: 20+ minutes/pt/calendar month.ii. Must count time of only one clinical staff member/task CCM Time = 10 min. (Not 10min X 2 = 20 min)

Example: i. Communication with home health agencies & other community service providers.

ii. May not concurrently bill CMS in same calendar month for: CCM (99490) and HHC Supervision (G0181) TCM Services (99494/99496) ESRD Codes (90951-90970)

ReimbursementBilling & Coding

• The Medicare payment allowance for CCM services will be $42.60 per beneficiary per calendar month

• Services billed by a hospital outpatient provider will be paid at the facility rate ($9.00 less) than the non-facility rate. However, the hospital may bill a separate facility fee for CCM.

• Services are subject to the usual Medicare beneficiary cost sharing—deductible/coinsurance. ($8/mo)

• Document care plan in the patient’s medical record. Comprehensive care plan: established/implemented/revised/monitored.

ReimbursementBilling & Coding

• Use CPT code 99490 CCM services 20-59 minutes.• Use CPT code 99487 CCM services 60-89 minutes.• Use CPT code 99487 + 99489 services 90-119 minutes.• Use CPT code 99487 + 99489(X2) services 120+ minutes.

• “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”

• No specified edits for place, date, or site of service. Consider DOS as the day the time criteria was met; site as practice location; and at least 2 chronic conditions as the dx codes.

ReimbursementBilling & Coding

• CCM and 99091 (An additional $56.92/mo.?) Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time. (Does not require the beneficiary to be present.)

Must be combined with an E&M (99201-99499); however—CMS appears to consider this part of the activity for CCM. TechHealth Perspectives November 5, 2014 Amy Lerman Saturday, Nov. 1, 2014, The American Telemedicine Association (ATA) “Update on CMS Payment Decisions - Two Steps Forward, One Back”

• Services are subject to the usual Medicare beneficiary cost sharing—deductible/coinsurance. ($8/mo)

• CCM services are believed to be duplicative of the per-patient-per-month payment practices already received by providers for participating in these initiatives

• Document care plan in the patient’s medical record. Comprehensive care plan: established/implemented/revised/monitored.

What to do:

1. Identify patients that qualify.

2. Educate patients/families & obtain written consent.

3. Look at EMR functionality current mechanism for documenting office support services.

4. Perform gap analysis to determine IT/office needs.

5. Create a patient-centered care plan check list.

6. Identify how the full care team will communicate & execute care plan.

Chronic Care Management Scope of Services Check List

1. Patient must have access to care management services 24 X 7. 2. Designated provider for each patient.3. Continuity of care provider for patient.4. Care management for chronic conditions.5. Facilitate/manage care transitions between health care providers & settings.6. Coordination with home & community-based clinical service providers.7. Creation of a comprehensive patient-centered care plan (document).8. Care must be congruent with patient choices and values.9. Care management must asses Medical/Functional/Psychosocial needs of pt.10. Care plan must be accessible to the full care team 24/7.11. Care plan must be accessible to patient/designee via web-based portal 24/7, as

well. 12. Care plan available to community-based service providers.13. Care plan must be shared amongst the whole team/patient-designee. 14. Care plan does NOT have to be created/transmitted by EHR alone, other tech OK. 15. Enhanced communication modalities between patient and medical provider. 16. Electronic capture and sharing of care plan information.

FAQ’s

1. Does the practice have to be a PCMH? No.2. Is the annual wellness visit required. No. (But, encouraged.)3. Does the CCM have to be initiated during an in-person visit? Yes.4. Is CCM recognized as a RHC or FQHC? No, not reimbursed.5. Can CMS Multi-Payer Advanced Primary Care Practice Demonstration & the

Comprehensive Primary Care Initiative bill for CCM? No.6. Has CMS provided a list of “chronic conditions” or offer guidance on acuity? No.7. Is there a standard process for a beneficiary to revoke the CCM? No.8. Is time preparing/updating care plan part of CCM? No, it’s a separate E&M service.9. When should a CCM claim be submitted? Anytime after the 20 min requirement.

Questions?

Resources

• Chronic Care Management and Other New CPT Codes, Kent Moore, Family Practice Management, 2015.

http://www.aafp.org/practice-management/payment/coding/ccm.html

• Providing and Billing Medicare for Chronic Care Management, Pershing, Yoakley & Associates, March, 2015.

• http://www.pyapc.com/resources/collateral/white-papers/Chronic-Care-Whitepaper-PYA.pdf

• New Codes for Transitional Care Management, Thomas Weida, MD, WVAFM, April, 2014.

Example of Patient Agreement