Presentation on theme: "Medicare Update: Chronic Care Management"— Presentation transcript:
1 Medicare Update: Chronic Care Management William C. Thornbury, Jr., MD, FAAFP
2 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
3 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
4 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.
5 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.
6 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.”
7 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
8 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/yr20 pts/day => $150,000/yr
9 So What? Proposed legislation to repeal the SGR: TomorrowProposed 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” byMcClatchy Washington Bureau March 19, 2015
10 So What? Proposed legislation to repeal the SGR: TodayModest 0.61RVU = $42.39 monthly.Benjamin Franklin Says:4 pts/day X 4.5 day/wk X 50 wk X $42/mo = $ 37,500/yr20 pts/day => $150,000/yrTomorrowProposed 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” byMcClatchy Washington Bureau March 19, 2015
11 Chronic Care Management Provider 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.
12 Chronic Care Management Patient Eligibility Patients require:2 or more chronic conditionsExpected to last 12 months, or until patient deathPlace the patient at significant risk of death, acute exacerbation/decompensation, or functional declinePatient/Designate must agree and give written consent
13 Chronic Care Management 3 Global Requirements Secure beneficiary’s written consent.Five specified capabilities.Use a 2011/2014 certified EHR for specified purposes: (See Final Rule p. 474.)Maintain an electronic care planEnsure beneficiary access to careFacilitate transitions of careCoordinate care20+ Minutes of non-face-to-face care management servicesMay be performed by licensed clinical staff under supervisionAPRNs, PAs, RNs, LSCSWs, LPNs, and CNA’sEncounter time may not be rounded up
14 A. Patient ConsentBeneficiary 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.
15 A. Patient Consent Documentation 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.
16 A. Patient Consent Revocation 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.
17 B. Five Specified Capabilities 1. CCM Certified EHR Technology “Meaningful Use” EHR not required.CCM (2011/2014) certified technology is.Must Record:DemographicsProblem ListsMedicationsAllergiesTransmit Summary of Care RecordConsent of BeneficiaryProvide Care Plan to BeneficiaryCommunicate Care Coordination
18 B. Five Specified Capabilities 2. 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 careAssessment of functional status of the chronic health conditionsAssessment of cognitive/mental health conditions that could impair self-careAssessment of preventive health needsBe congruent with patient choices and valuesAddress all health needs, not just chronic diseaseUpdate at least annuallyStored “electronically”
19 B. Five Specified Capabilities 2. Care Plan Document CMS has not specially required defined elements in the care plan; however, it has identified items typically included:Problem listMeasureable treatment goals, outcomes & prognosisSymptom management & planned interventionsAll recommended preventive care servicesCommunity/Social services to be accessedPlan of care coordination with other providersResponsible individual for each interventionOversight: patient self-management of medicationsMedication reconciliation and managementMed list, drug allergies, review of adherence & potential interactionsRequirement for periodic review & revision
20 B. Five Specified Capabilities 2 B. Five Specified Capabilities 2. Care Plan Coordination & CommunicationCMS 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”.
21 B. Five Specified Capabilities 3. 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”
22 B. Five Specified Capabilities 3. Continuity of Care The patient must be able to obtain successive routine appointments with a designated provider/care team member.
23 B. Five Specified Capabilities 3. Enhanced Communication Provide enhanced opportunities for beneficiary—provider communication.Should include:Telephone/SmartphoneSMS/Secure MessagingInternet/ Web-based accessTelemedicinemHealth“and other asynchronous ornon-face-to-face methods”
24 B. Five Specified Capabilities 4. 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.
25 B. Five Specified Capabilities 4. 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.
26 B. Five Specified Capabilities 5. 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:Home HealthOutpatient Therapies (PT/OT/ST)Durable Medical Equipment coordinationTransportation ServicesNutrition ServicesHospiceProvider communication with these services must be documented in “CCM certified technology”.Care team and family/caregiver must have electronic access.
27 C. 20+ Minutes of Non-Face-to-Face Services Care Management Services require 20+minutes non-face-to-face communication in a given calendar monthMay be fulfilled by licensed clinical staff under supervision.ExamplesPerforming medication reconciliation/overseeing the beneficiary’s self- management of medications.Ensuring receipt of recommended preventive services.Monitoring the beneficiary’s condition: (physical/mental/social)Address questions from patient/family/guardian/caregiver.Provide education to patient/caregiver.Identify and arrange for community resources.Communicate with home health agencies and other community service providers utilized by the beneficiary.
28 C. 20+ Minutes of Non-Face-to-Face Services Supervision Communication by licensed staff:General Supervision is all that is required.Provider available by phone.Available provider does NOT have to be same as CCM provider.May contract-out services to 3rd party.“Subscription services” could include after-hours availability.
29 C. 20+ Minutes of Non-Face-to-Face Services Documentation CMS does not list explicit documentation requirements.Compliance for audit of services may wish to include:Date & amount of time (start/stop times) for servicesClinical staff & credential furnishing servicesBrief description of servicesTime 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).
30 C. 20+ Minutes of Non-Face-to-Face Services Documentation Example:Time: 20+ minutes/pt/calendar month.Must count time of only one clinical staff member/taskCCM Time = 10 min. (Not 10min X 2 = 20 min)Example:Communication with home health agencies & other community service providers.May not concurrently bill CMS in same calendar month for:CCM (99490)andHHC Supervision (G0181)TCM Services (99494/99496)ESRD Codes ( )
31 Reimbursement Billing & Coding The Medicare payment allowance for CCM services will be $42.60 per beneficiary per calendar monthServices 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.
32 Reimbursement Billing & Coding Use CPT code CCM services minutes.Use CPT code CCM services minutes.Use CPT code services minutes.Use CPT code (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.
33 Reimbursement Billing & Coding CCM and (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 ( ); however—CMS appears to consider this part of the activity for CCM.TechHealth Perspectives November 5, 2014 Amy LermanSaturday, 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 initiativesDocument care plan in the patient’s medical record.Comprehensive care plan: established/implemented/revised/monitored.
34 What to do: Identify patients that qualify. Educate patients/families & obtain written consent.Look at EMR functionality current mechanism for documenting office support services.Perform gap analysis to determine IT/office needs.Create a patient-centered care plan check list.Identify how the full care team will communicate & execute care plan.
35 Chronic Care Management Scope of Services Check List Patient must have access to care management services 24 X 7.Designated provider for each patient.Continuity of care provider for patient.Care management for chronic conditions.Facilitate/manage care transitions between health care providers & settings.Coordination with home & community-based clinical service providers.Creation of a comprehensive patient-centered care plan (document).Care must be congruent with patient choices and values.Care management must asses Medical/Functional/Psychosocial needs of pt.Care plan must be accessible to the full care team 24/7.Care plan must be accessible to patient/designee via web-based portal 24/7, as well.Care plan available to community-based service providers.Care plan must be shared amongst the whole team/patient-designee.Care plan does NOT have to be created/transmitted by EHR alone, other tech OK.Enhanced communication modalities between patient and medical provider.Electronic capture and sharing of care plan information.
36 FAQ’s Does the practice have to be a PCMH? No. Is the annual wellness visit required. No. (But, encouraged.)Does the CCM have to be initiated during an in-person visit? Yes.Is CCM recognized as a RHC or FQHC? No, not reimbursed.Can CMS Multi-Payer Advanced Primary Care Practice Demonstration & the Comprehensive Primary Care Initiative bill for CCM? No.Has CMS provided a list of “chronic conditions” or offer guidance on acuity? No.Is there a standard process for a beneficiary to revoke the CCM? No.Is time preparing/updating care plan part of CCM? No, it’s a separate E&M service.When should a CCM claim be submitted? Anytime after the 20 min requirement.
38 ResourcesChronic Care Management and Other New CPT Codes, Kent Moore, Family Practice Management, 2015.Providing and Billing Medicare for Chronic Care Management, Pershing, Yoakley & Associates, March, 2015.New Codes for Transitional Care Management, Thomas Weida, MD, WVAFM, April, 2014.