Presentation on theme: "Introduction to the Chronic Care Management Code March 12, 2015"— Presentation transcript:
1Introduction to the Chronic Care Management Code March 12, 2015 Nicole Liffrig Molife(202)Paul M. Rudolf, MD,(202)
2BackgroundPreviously, non-face-to-face care management was bundled into Evaluation/Management (E/M) services.Payment for E/M services did not adequately account for the amount of work to provide complex, coordinated care management for beneficiaries with multiple chronic conditions.New Current Procedure Terminology (CPT) Code 99490National Payment Rate for Chronic Care Management (CCM) in the non-facility setting is $41.92 per beneficiary per month.Medicare will also pay hospitals under the Hospital Outpatient Prospective Payment System (APC 0631, $53.72)Physician paid at the facility rateBeneficiary is responsible for the 20% co-insurance.MA Plans must offer enrollees at least traditional FFS benefits which now include CCM, and will presumably pay for CCM in the way it currently pays for other physician services.Commercial payors will likely follow pay for CCM code because payors often follow CMS’ payment policy.In addition, CPT created a code for Complex Chronic Care Management (CCCM),Today, CMS does not pay for CPT Code
3CCM Requirements Eligible patients Eligible professionals Patient consentCare coordination servicesSpecified practice capabilitiesSpecified use of EHR
4CCM Requirements Eligible patients Eligible professionals Patient consentCare Coordination ServicesSpecified practice capabilitiesSpecified use of EHR
5Eligible Patients Patients must: Have two or more chronic conditions that are expected to last at least 12 months (or until death), thatPlace them at significant risk of death, acute exacerbation/decompensation, or functional decline.CMS has declined to publish a definition of qualifying “chronic conditions” and is allowing practices to make their own determinations about beneficiary eligibility.Although most observers believe the Centers for Medicare & Medicaid Services (CMS) expect many patients to qualify and for CCM to be billed frequently, practices must keep in mind that the services must be medically necessary.
6CCM Requirements Eligible Patients Eligible professionals Patient consentCare Coordination ServicesSpecified practice capabilitiesSpecified use of EHR
7Eligible Professionals Who may bill for CCM services?Physicians (any specialty)Advanced practice registered nursesPhysician assistantsClinical nurse specialistsCertified nurse midwivesOnly one provider may bill CCM per patient per month.If more than one provider bills, the first claim submitted will be paid.
8Eligible Professionals (Cont.) Who may provide CCM services?CCM services may be provided by clinical staff, incident to the services of a physician or mid-level practitioner, under the general supervision of that physician or practitioner.The supervising physician’s time may also count, but the physician must be performing specified CCM activities (time spent supervising does not count).
9Eligible Professionals (Cont.) Clinical staff include:Licensed professionals: nurses, technicians, therapistsNon-physician practitioners: physician assistants, nurse practitionersCCM services must “be provided by clinical staff, specifically, rather than by other “auxiliary personnel” as is the case for other “incident to” rules.Beyond suggesting that the definition of “clinical staff” is more narrow than “auxiliary personnel,” CMS does not elaborate on what credentials clinical staff must have to provide CCM services.Nevertheless, staff must be qualified to provide CCM support (e.g., administrative staff do not qualify).Further clarity is needed to determine whether clinical staff with a defined scope of service but who may not be licensed or have “official” credentials (e.g., medical assistants) are eligible to provide CCM services.
10General Supervision General supervision: Physician is not required to be present in the office at the time the service is furnished.CMS has not defined what activities count towards satisfying the “general supervision” requirement for CCM services, but may include:Team meetings/calls with clinical staff providing CCM services.Ultimately, supervising physician must provide sufficient oversight to demonstrate ongoing participation in the patient’s care and that CCM is being delivered as part of the prescribed course of treatment.Physician should document supervision activities
11Employment Arrangements Clinical staff need not be direct employees of the practitioner or the practice.May be independent contractors.Our understanding is that clinical staff are not required to be W-2 employees.There must be a “close relationship” between the practitioner and clinical staff providing the services.Scope of services that may be provided under arrangement has not been defined.Physician supervision is required and may be more difficult to support if staff is not on-site.
12CCM Requirements Eligible patients Eligible professionals Patient consentCare coordination servicesSpecified practice capabilitiesSpecified use of EHR
13Patient ConsentPractices must obtain written consent from the beneficiary to bill the CCM code.Consent must be documented in the electronic health record.Practice must:Inform the beneficiary of the availability of CCM services;Explain the type of services included in the CCM benefit;Inform the beneficiary of the right to stop the CCM services at any time;Notify the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month; andInform the beneficiary that they will be responsible for any associated copayment or deductible.Beneficiary can terminate consent at any time.Retroactive consent not allowedDiscussion point: refusal of beneficiary to consent.
14CCM Requirements Eligible patients Eligible professionals Patient consentCare coordination servicesSpecified practice capabilitiesSpecified use of EHR
15Care Coordination Services Minimum of 20 minutes of non-face-to-face care coordination services, such as:A provider may not count time spent by multiple clinical staff during a single meeting more than once.If three staff members meet for 10 minutes to discuss a beneficiary’s chronic care management, only 10 minutes may be counted toward the billing code.There are also a number of services for which a provider may not bill during a calendar month when CCM is billed, e.g., transitional care management (CPT and 99496).Conversely, CCM cannot be billed for a calendar month during which TCM is billed (e. g., if TCM is billed for the period Jan. 5 to Feb 4, CCM cannot be billed for Jan. or Feb.)Additionally, CPT Code may not be reported during a month when the monthly ESRD capitation is billed or by a provider during the postoperative period of a reported surgery.
16Care Coordination Services (Cont.) CMS has identified a non-exhaustive list of services that can be counted towards the 20 minutes/per month requirement, including:Development/revision of care planCoordination with other treating HCPsMonitoring a patient’s physical, mental and social needsEnsuring timely receipt of preventive care servicesPerforming medication reconciliationSupervising patient self-management of medicationsManaging care transitions, including follow-up after emergency department visits and discharges from facilitiesCoordinating home and community based clinical service providers required to support the patient’s mental and social needsAdditional care coordination/management services can be found at: 79 Fed. Reg
17Documentation of Clinical Staff Activities CMS has provided little guidance regarding the level of documentation required to bill the code.Billing providers should require clinical staff to document their time and describe the CCM service that was performed (i.e., coordinating care, communicating with the patient, etc.)One Medicare contractor suggested that care team members can record time increments as either “5 min.” or “10:05am – 10:10am.”The AAFP has posted several CCM tools, including a sample time entry log, available at
18CCM Requirements Eligible patients Eligible professionals Patient consentCare coordination servicesSpecified practice capabilitiesSpecified use of EHR
19Practice Capabilities To bill the new CCM code, practices must provide:24/7 patient access to address patients’ acute chronic care needs;Continuity of care through a designated member of the care team;Care management including systematic assessment of patient’s medical, functional, and psychosocial needs;Creation of a comprehensive patient-centered care plan document (which must be provided to the patient);Management of care transitions within the health care system; andEnhanced opportunities for provider-patient communications. The care plan must be provided to the patient, but need not be provided electronically.
20Practice Capabilities (Cont.) Practices should be careful to distinguish between:(A) The capabilities CMS requires a provider to have to bill for CCM (e.g., use of a certified EHR for specified purposes, coordinate care, maintain an electronic care plan, etc.); and(B) When services count towards the 20 minute minimum (e.g., clinical staff time can only be counted if the clinical staff person meets the requirements for electronic access to the care plan)
21CCM Requirements Eligible patients Eligible professionals Patient consentCare coordination servicesSpecified practice capabilitiesSpecified use of EHR
22The Care PlanProviders must electronically capture care plan information in a certified electronic health record (EHR) or other HIPAA-compliant health information exchange platform.All care team members furnishing CCM services that are billed by a given practice must have 24/7 access to the electronic care plan information in order to count their time toward the 20 minutes.Practice also must share care plan information, as appropriate, with other providers outside of the practice, using any electronic means (other than fax).
23The Care Plan: Providing Access The language of the final rule appears to provide some discretion to practices in the manner in which contracted clinical staff can access the patient’s care plan and the amount of information they are required to have.Remote access to the EHR.Web access to a care plan application.Web-based access to a health information exchange service that captures care plan information.
24The Care Plan: Providing Access (Cont.) One Medicare Contractor has suggested that, in the highly unlikely event that a billing practice that is coordinating care or referring a patient to a non-CCM billing practitioner who has no internet access, capability or ability to receive the care plan electronically, then time spent coordinating with that cannot be billed.We disagree, given the preamble explicitly states:the electronic care plan “would not have to be available at all times to other non-billing practices, recognizing that other practices may not be using compatible electronic technology or participating in a health information exchange.” 79 Fed. Reg
25Use of EHRCertified EHR technology is only required for specified services, including:Practice must create a structured recording of demographics, problems, medications and medication allergies.This information must inform the care plan (although the care plan itself does not need to be created or transmitted using a certified EHR), care coordination, and ongoing clinical care.Practice must create a structured clinical summary record that is formatted according to, at a minimum, the standard for the EHR Incentive Program requirements from the previous calendar year.Practice must document in the patient’s medical record using the certified EHR:Patient’s written consent an authorization for CCM services.Practice must also document that all of the CCM services were explained and offered, and note the patient’s decision to accept or decline these servicesThat a written or electronic copy of the care plan was provided to the patient.Communication to and from home and community based providers regarding the patient’s psychosocial needs and function deficits.
26Confusion Regarding the Use of EHR One Medicare Contractor has suggested that all practitioners and clinical staff whose time is counted towards the 20 min. requirement must have 24/7 access to the patient’s EHR.We disagree with this interpretation of the rule, and believe that the 24/7 requirement only applies to accessing the electronic care plan (which does not require transmittal via EHR).The Final Rule states that “the CCM service must be furnished using [CCM certified EHR technology] to meet the final core-technology capabilities [and] to fulfill the CCM scope of services requirements whenever the requirement references a health or medical record.” (79 F.R )Nowhere in the rule does it state that care team members counting time towards the 20 min. requirement must have 24/7 access to the EHR.However, there is no clear guidance on this issue and it remains a grey area.
27Use of EHR: Privacy Concerns Providing access to off-site clinical staff may raise privacy concerns, albeit not new ones.CCM rule requires physicians to document patient authorization for electronic communication of his or her medical information to be shared with other treating providers in the EHR.Clinical staff team members (or their employers) who are not part of the practice should sign business associate agreements.
29Potential Business Opportunities Opportunities for billing providers/practicesOpportunities for vendors
30Opportunities for Billing Providers/Practices New revenue source.Ability to develop infrastructure to become a medical homes or to participate in ACOs.Differentiate practice / provider for payors.
31Opportunities for Vendors Vendors can assist providers by:Developing systems and platforms to assist in administrative tasksProviding remote technology platforms to facilitate practices meeting the 24/7 access and provider-patient communications scope of serviceOpportunities also exist to provide clinical staff on a contract basis to billing providers.
33Legal Risks: The Anti-Kickback Statute and Stark Law Because physicians may be in a position to refer business to vendors supplying CCM-related services, arrangements between physicians and vendors should comply with the federal Anti-Kickback statute.Arrangements between physicians and vendors for the provision of CCM-related services could implicate the Stark Law if there is the potential for referrals for DHS between the two parties.
34Other Legal RisksCompanies seeking to innovate in the area of enhanced provider-patient communications should consider:FDA requirementsMedical data privacy and security laws (e.g. HIPAA),Product liability risks (e.g., should the product fail to deliver essential communications)Other tort or contractual claimsCompanies providing clinical staff should consider:State licensure lawsState “fee-splitting” prohibitions (that proscribe certain healthcare professionals from splitting professional fees with providers),Corporate practice of medicine prohibitions (that bar corporations or other lay entities from practicing medicine and or interfering with a doctor’s independent clinical judgment).
35Open IssuesCMS has declined to provide guidance with respect to use of CPT 99490We have already become aware that Medicare Administrative Contractors and certain consultants appear to have given advice that is not consistent with advice given by specialty societiesPhysicians may want to consult experienced health care legal counsel
37AcknowledgementWe would like to thank the following Arnold & Porter associates for their assistance in preparing the presentation: Lauren Haertlein, Elizabeth Owens, Nora Schneider, and Victoria Wallace.
38Paul M. Rudolf, MD (202) 942-6426 Paul.Rudolf@aporter.com Thank youPaul M. Rudolf, MD(202)Nicole Liffrig Molife(202)