MEDICARE'S CCM PROGRAM: OPPORTUNITIES AND CHALLENGES

By Michael Stearns, MD, CPC, CFPC

The 2015 Medicare Physician Fee Schedule (PFS) Final Rule has approved the use of CPT code 99490 to reimburse providers who manage Medicare patients with two or more chronic health conditions. Providers have the potential to earn substantial revenue, up to approximately $500 per patient per year, through the Chronic Care Management (CCM) program, which went into effect on January 1, 2015. It’s a unique opportunity to be compensated for services practices already provide and to make long-term investments in technology and services that will benefit a critical patient population. A core requirement for this program is that licensed clinical staff members spend at least 20 minutes each month providing non-face-to-face care of eligible Medicare patients. However, CCM also has a number of requirements that each practice should carefully review before deciding to participate. This article provides an overview.

Note that a complete understanding of CCM requires a review of the Medicare 20141 and 20152 PFS Final Rules, the American Medical Association’s 2015 Current Procedural Terminology (CPT) code book3 section on Chronic Care Management, the Medicare Chronic Care Management Fact Sheet4, and information provided by Medicare during a National Provider Call (NPC) on February 18, 2015.5, 6 Readers are also strongly encouraged to review compliance requirements for the CCM program with their Medicare Administrative Contractors7 (MACs) as it emerges.

CCM Program Requirements, With Challenges and Recommendations

  1. Authorized ("Billable") Providers Who Can Participate: Billable providers may be physicians, nurse practitioners, physician assistants, clinical nurse specialists, and nurse midwives.
  2. Authorized ("Non-Billable") Clinical Staff Members Who Can Provide CCM Services: Authorized clinical staff members who can provide CCM services may be licensed clinical staff members, such as registered nurses or certified medical assistants, who are practicing within the scope of their practice as defined by the licensure requirements of their state.

    Practices need to ensure that the licensed staff member’s scope of practice in performing CCM services is compliant with state requirements. He or she must provide CCM services under the "general supervision" of the attending physician or provider. These services may be provided by clinical staff members who are not employed by the practice, such as employees of third party organizations, as long as they are acting under the general supervision of the CCM provider. The designated CCM provider does not need to be physically present when the CCM service is provided by clinical staff, but other "incident to" requirements remain in effect.
  3. Patient Eligibility Requirements: Patients must be Medicare beneficiaries with two or more chronic conditions. The Medicare 2015 Final Rule defines a chronic condition as: "…chronic continuous or episodic health conditions that are expected to last at least 12 months, or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline." In the Medicare CCM Fact Sheet, Medicare lists the following 13 conditions as examples that qualify under this definition: Alzheimer’s disease and related dementia, arthritis (osteoarthritis and rheumatoid), asthma, atrial fibrillation, autism spectrum disorders, cancer, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, ischemic heart disease, and osteoporosis. During the February 18 NPC, the Medicare representatives shared that their software would not reject claims based on ICD diagnosis codes used to support claims for CCM services. They suggested it was up to provider to determine whether the patient has at least two chronic health conditions based on the definition above.
  4. Patients Must Identify One Provider per Month to Provide CCM Services: Patients need to designate a single provider to be their CCM care provider per month. (This is a component of the patient consent process, which will be addressed further below.) Medicare will only pay one CCM fee per month per patient. This has the potential to create management and referral challenges, especially when two providers are managing two or more chronic diseases for a given patient.
  5. Non-Face-to-Face CCM Services: CCM services require "enhanced opportunities for the beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary’s care through, not only telephone access, but also through the use of secure messaging, internet or other asynchronous non face-to-face consultation methods." This may include secure messaging via e-mail, patient portals, telehealth encounters, and other means of communication.
  6. Applicable CCM Services: Following is a list of examples of CCM services that can be provided via non-face-to-face interactions that qualify for the CCM program:
    1. Medication reconciliation with review of adherence and potential interactions
    2. Oversight of patient self-management of medications
    3. Systematic assessment of the patient’s medical, functional, and psychosocial need
    4. Validating the patient has received all recommended preventive care service
    5. Patient education
    6. Answering questions from the patient and/or their caregiver
    7. Coordinate community resources and arrange for any needed support or assistance; including home health agencies, rehabilitation centers, etc.
    8. Documentation related to patient care, including structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record."
  7. Minimum CCM Service Time Per Patient Per Month: In order to qualify for billing, one or more clinical staff members must engage in a total of 20 minutes or more per calendar month of non-face-to-face CCM services per patient under the supervision of an authorized provider. As per the February 18, 2015 NPC, face-to-face interactions between clinical staff members and patients may also count as CCM service time, but only if they are services that are normally provided via a non-face-to-face encounter. The time spent does not need to be continuous or provided by a single individual staff member. Time spent in CCM services should not be counted when the patient is an inpatient in a hospital, resides in a facility, such as a skilled nursing facility, or take place on the same day that the patient is seen for an evaluation and management visit by the attending provider. Tracking the time, documenting what services were provided, summating the time per patient per month, and being able to generate a defensible audit report are some of the primary challenges associated with the CCM program. Practices are encouraged to investigate how this process can be accommodated by their current electronic health record (EHR), practice management, or scheduling system, or determine if they need to invest in manual workflow options or third party "time tracking" applications. Accountability needs to be taken into consideration. An audit in the future may request a very detailed accounting of CCM activities several years after the service was provided.
  8. Comprehensive Care Plan (Electronic): The provider furnishing chronic care management services must create and maintain an electronic, patient-centered comprehensive care plan 24 hours a day, seven days a week. The plan must be continuously updated and available to all care providers involved with the patient. This includes the CCM attending provider, clinical staff members providing CCM services, and providers external to the practice, such as specialists. The ability to generate a care plan may not be an automated process in many EHRs, so this may, in fact, require a degree of manual effort by the provider and the provider’s staff. The practice must document in the certified EHR when the care plan was provided to the patient. The care plan addresses, but is not limited to, the following aspects of the patient’s health:
    1. Problem list
    2. Expected outcome and prognosis
    3. Measurable treatment goals
    4. Symptom management
    5. Planned interventions
    6. Medications and their management, including medication compliance and reconciliation, addressing potential interactions and oversight of self-management of the patient’s medications
    7. Status of preventive care services
    8. The patient’s physical, clinical, social, psychological, functional and environmental needs and management plan
    9. The patient's support team including providers, family members, and roles, and how they are involved with coordinating care
    10. How the services of agencies and specialists unconnected to the practice will be directed/coordinated
    11. The patient’s choices and values
    12. Community/social services ordered
    13. Identify the individuals responsible for each intervention
    14. Requirements for periodic review and revisions to the care plan as necessary

The practice must have a mechanism whereby the electronic care plan can be shared with other practices, even with practices that may not be on an EHR. In most instances secure messaging may facilitate the transfer of this electronic care plan, but some practices may not have this capability.

Medicare does not restrict the type of electronic tool to be used to share the care plan, other than stressing that facsimiles are not allowed. On the February 18, 2015 NPC, the Medicare representative stated that some applications have the ability to convert an electronic document into a facsimile message and this would allow providers to communicate with practices that are not able to receive other forms of electronic messages. A care plan should be created and made available to all members of the patient’s care team prior to billing for CCM services. The care plan must be given to the patient in an electronic or paper form, and the fact that it was provided needs to be documented in the certified EHR.

  1. Continuity of Care: The patient needs to have a designated practitioner or member of the care team with whom the patient can schedule and receive successive routine appointments.
  2. Coordination with Home and Community Based Services: The practice must provide coordination of care services with home and community-based clinical service providers that have the ability to support the patient’s psychosocial needs and functional deficits. Communication to and from home and community based providers regarding these clinical patient needs must be documented in the practice’s medical record system.
  3. Access to Care 24/7: Practices must offer patients the means to gain "timely access" to providers in the practice 24 hours a day, seven days a week. During the February 18, 2015 NCP, the Medicare representative clarified that the covering provider does not need to be an employee of the practice as long as there was an appropriate contractual relationship in place between the healthcare professional and the practice providing the CCM service. Non-provider members of the care team may also provide support "after-hours" and this time can count toward the time needed to reach the minimum CCM time requirement of 20 minutes per month per patient.
  4. Management of Care Transitions: Participating providers are required to demonstrate they are providing oversight of referrals to other providers, post-emergency-department visits management, post-discharge care, and other transitions. The CCM code 99490 cannot be billed in the same 30-day period after discharge in which the Transitional Care Management codes (99495-99496) are also billed.
  5. Electronic Health Record Requirements: The Centers for Medicare and Medicaid Services (CMS) requires that practices use an EHR that is certified for Meaningful Use of EHRs by an Office of the National Coordinator for Health IT Authorized Testing and Certification Body using either 2011 or 2014 criteria. This is applicable for 2015 and may change in 2016. The EHR must be able to record demographics, problems, medications, and medication allergies in a structured format, at a minimum. Members of the chronic care team involved in the after-hours care of a patient must have access to the patient’s full electronic medical record, even when the office is closed so they can continue to participate in care decisions with the patient. However, there is no requirement at this time that providers outside of the practice—for example, specialists involved with the patient’s care—have access to the full electronic medical record.
  6. Summary Care Record: Practitioners providing CCM services must be able to generate a structured summary care record document. These features are available in 2011 and 2014 ONC-HIT certified EHRs. The health summary document needs to be updated and made available to all providers involved with the patient’s care, including during the process of care transitions.
  7. Initial Visit Requirements: During the February 18, 2015, NPC, the Medicare representative stated that a face-to-face visit was required prior to instituting CCM services. The Medicare CCM Services Fact Sheet8 states: "CMS requires the billing practitioner to furnish an Annual Wellness Visit, or Initial Preventative Physical Exam, or comprehensive evaluation and management visit to the patient prior to billing the CCM service, and to initiate the CCM service as part of this exam/visit." This was also addressed in the Medicare 2014 PFS Final Rule, but at that time an initial Annual Wellness Visit or Initial Preventive Physical Exam was described as a "recommendation." At this time further clarification is needed, but scheduling a comprehensive visit with the patient where all aspects of the care plan and informed consent can be established is recommended.
  8. Patient Consent Requirements: Patients need to provide written consent that states they agree to be enrolled in the CCM program and the consent form must be stored within the patient’s medical record. The Medicare CCM Fact Sheet states that an initial visit must occur where the CCM is explained in detail to the patient before CCM services can be initiated. The consent form must inform the patient that only one provider per month can serve as their designated CCM provider. It must also inform the patients of the range or services that will be made available to them under the CCM program. The patient has to consent to having their information shared electronically to other members of their care team. They also have to be informed of their right to discontinue CCM services at any time and the mechanism by which they terminate the CCM service. They must be informed that the CCM services will discontinue on the last day of the month in which they communicate with the practice that they no longer wish to receive CCM services. The patient’s consent form and the discussion surrounding the CCM program and its requirements, and the patient’s decision to participate or decline, must be stored in the electronic patient record.
  9. Patient Copayment Requirements: As with other Medicare services, other than preventive care, the patient is obligated to make a 20 percent copay under this program (roughly eight dollars a month). In some cases, this may be addressed at least partially by coinsurance. However, the CCM program was designed to give Medicare providers the funding they will need to invest in additional resources, including personnel and technology, needed to address the complex needs of patients with multiple chronic conditions. Explaining the value the program brings to each patient’s care may encourage them to participate.
  10. Other Billing Considerations: Providers will need to submit one 99490 CCM code each calendar month for each patient that meets the CCM criteria. Medicare did not specify a specific date to be used as date of service, but they did share that this date would be flexible. However, the claim should not be submitted until all requirements have been met—particularly that 20 minutes or more of qualified CCM time has been provided to the patient. Providers may bill for evaluation and management services and other usual services in the same calendar month as they bill for CCM. Exceptions include no concurrent billing with Transitional Care Management codes (99495-99496), Home Healthcare Supervision (HCPCS code G0181), Hospice Care Supervision (HCPCS code G0182, and certain End Stage Renal Disease (ESRD) Services (CPT 90951-90970). Other considerations apply and may be further defined by the AMA CPT code book, by MACs, and by further guidance from CMS.
  11. Program Cost and Audit Considerations: Medicare estimated that approximately two-thirds of Medicare patients have two or more chronic conditions. The goal of the CCM program is to improve the health of these patients while reducing the cost of healthcare. However, if a significant percentage of this patient population receives CCM services, the cost of the CCM program could exceed several billion dollars per year. For this reason, and fact that the complexities of the CCM program may lead to inaccurate coding and documentation, it is likely to be subjected to a fair amount of scrutiny. Practices are encouraged to structure their implementation and documentation of CCM services in ways that are accountable and transparent, and to perform ongoing internal audits as warranted. In addition, the Medicare representative on the February 18, 2015 NPC deferred several detailed questions about the program to the MACs. Practices are strongly advised to review any requirements provided by your MAC, if available, before initiating the CCM program in your practice.

Summary

The CCM program represents a significant opportunity for Medicare providers to extend their support for patients with multiple chronic conditions. As detailed above, the program can also be financially rewarding. However, it has a number of operational, workflow, and compliance requirements that make engagement in the CCM initiative a significant undertaking. Practices will, in many cases, need to invest in additional resources, operational oversight and technologies that will allow them to best serve the CCM patient population.


NOTES

1. Federal Register 78, 237; p. 74230. Available at http://www.gpo.gov/fdsys/pkg/FR-2013-12-10/pdf/2013-28696.pdf.  BACK TO TEXT

2. Federal Register 79, 219; p. 67548. Available at
https://www.federalregister.gov/articles/2014/11/13/2014-26183/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory.  BACK TO TEXT

3. American Medical Association. Current Procedural Terminology, 2015 Professional Edition. Chicago: American Medical Association, 2014.  BACK TO TEXT

4. Centers for Medicare and Medicaid Services. Chronic Care Management Services Fact Sheet. Baltimore, MD: Medicare Learning Network, January 2015. Available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf.  BACK TO TEXT

5. Centers for Medicare and Medicaid Services. CMS National Provider Call Presentation: Chronic Care Management Services CY 2015 Medicare Physician Fee Schedule. Baltimore, MD: Medicare Learning Network, February 18, 2015. Available athttp://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-02-18-Chronic-Care-Presentation.pdf.  BACK TO TEXT

6. Centers for Medicare and Medicaid Services. CMS National Provider Call on Chronic Care Management Services Transcript. Baltimore, MD: Medicare Learning Network, February 18, 2015, Available at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-02-18-CCM-Transcript.pdf.  BACK TO TEXT

7. Medicare Administrative Contractor (MAC) Directory. Available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map.  BACK TO TEXT

8. Centers for Medicare and Medicaid Services. Chronic Care Management Services Fact Sheet. Available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf.  BACK TO TEXT

REFERENCES

1. American College of Physicians. Chronic Care Management Tool Kit — What Practices Need to Do to Implement and Bill CCM Codes. Philadelphia, PA: American College of Physicians, 2015. Available at http://www.acponline.org/running_practice/payment_coding/medicare/chronic_care_management_toolkit.pdf.

2. Moore, Kent. "Chronic Care Management and Other New CPT Codes." Family Practice Management 22, no. 1. (Jan-Feb 2015): 7-12.

3. Chronic Conditions Data Warehouse. Available at https://www.ccwdata.org/web/guest.


Michael Stearns
, MD, CPC, CFPC, is the CEO and founder of Apollo HIT.