Chronic care management (CCM) services are eligible for Medicare reimbursement to physicians and other qualified health care practitioners (OQHPs), such as nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants. Beginning back on January 1, 2015, a per beneficiary, once per calendar month fee is payable for qualifying non-face-to-face care coordination and care management services of at least twenty (20) minutes of clinical staff time provided or directed by the physician or OQHPs to eligible Medicare beneficiaries.

The following CPT codes are part of the CMS CCM program:

Chronic Care Management:

CPT 99490

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

CPT 99491

Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, 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

Complex CCM:

CPT 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 the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional 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, per calendar month

G2058

New add on code for non-complex CCM clinical staff time (additional 20 min)

G2065

Principal Care Management –  30 minutes of clinical staff time for patients with only one Chronic high risk Condition.

G2064

Principal Care Management –  30 minutes of physician time for patients with only one Chronic high risk Condition.

New Changes: New care plan requirements for both CCM and PCM.

CCM Program Description and Compliance

Eligible Medicare beneficiaries are patients with two or more
chronic conditions expected to last at least twelve months, or until the
patient’s death. Chronic conditions are those that place the patient at
significant risk of death, acute exacerbation or decompensation, or functional
decline.

CCM services are limited to Medicare patients residing at home
or in a domiciliary, rest home or assisted living facility. With approximately
2/3 of the Medicare population eligible, CCM is designed to be a critical
component of primary care that contributes to improved health and reduced
expenditures for the program and its beneficiaries. Payment for CCM finally
acknowledges the amount of time that physicians and their clinical staff spend
managing and coordinating care for chronically-ill Medicare patients outside of
an office visit.

Due to a lack of explanation in the MPFS final rules and CPT
manual, legal and compliance risks have arisen for CCM coding, documentation,
billing and reimbursement. CMS did not establish a new set of standards for
billing CCM services. Instead, CMS decided to emphasize that certain
requirements are inherent in the elements of the existing scope of services and
stated that these requirements must be met in order to bill CCM services. These
requirements are complex and ill-defined.

The CCM requirements and legal/compliance activities are
described below.

Risk of death, acute exacerbation or decompensation, or
functional decline:

Compliance: No information has
been provided by CMS on how to determine or document the specific acuity level
of a chronic condition but did confirm that risk must be documented and located
in the patient record.

Patient Information and Consent

Prior to initiating CCM services, the medical practice must
obtain the patient’s written consent to the furnishing of CCM services. The
consent must be included in the patient’s medical record. The consent must take
the form of a voluntary, informed beneficiary agreement that discusses:

  • Availability and description of non-face-to-face CCM services;
  • Payment of any deductible and $8.50 coinsurance per monthly CCM claim;
  • Authorization for the electronic communication of the patient’s medical information to other treating providers as part of care coordination;
  • Provision of a written or electronic copy of the care plan to the beneficiary;
  • Limitation of only one practitioner being paid for CCM services during the calendar month; and
  • Right to revoke CCM consent at any time and the effect of revocation on CCM services.
  • The consent process is not separately billable as a CCM service.

Legal/Compliance: CMS did not provide a model consent form or specify the
effect of a declination or revocation of CCM. If the beneficiary declines the
CCM services, or revokes the CCM consent, the practice will need to decide the
scope of care coordination and care management services it will provide to
declining/revoking patients. Additionally, if conducting telephone program
enrollments, how do you prove all requirements were discussed and consented to
by the patient?

CCM Coding and Billing Requirements

Payment for 99490 is estimated $42.60 per patient per month if
20 or more minutes of qualifying CCM is provided in the calendar month. Medicare
deductible and coinsurance will apply because CCM is not a preventive service
and exempt from beneficiary cost-sharing. Patients will pay $8.50 in
coinsurance per month services are billed. CMS will pay only one CCM claim per
beneficiary per month. If competing claims are submitted, the MAC will likely
pay the provider with the most recent valid patient consent. Neither MPFS nor
the CPT manual provides guidance on how to document the provision of CCM
services in the medical record for billing purposes. As with other time-based
services, the provider’s template should contain date, service time start and
stop, description of the service and name/credentials of the clinical staff.

Legal/Compliance: Monthly CCM payment is not automatic. Standard
CMS time-based counting rules of rounding up from the midpoint do not apply.
Tracking, recording time and managing the coding exceptions applicable to
non-face-to-face services is not a typical activity for medical practices. Activities
that “qualify” must be present, date/time of occurrence, must be contact
driven, time must reflect exact minutes for each entry and each entry must
stand alone in supporting billing the CPT code.
Beneficiaries may question why an $8.50 monthly payment is
required from them. Considering the beneficiary inducement and waiver of Part B
coinsurance prohibition, what will the practice’s policy be for patients who do
not pay the coinsurance?

CCM Care Plan

Requires that a comprehensive, patient-centered, electronic care
plan consistent with the patient’s choices and values be established,
implemented, revised and monitored. It must be based a physical, mental,
cognitive, psychosocial, functional and environmental (re)assessment and an
inventory of resources and supports available to and/or used by the patient and
is a comprehensive care plan to address all health issues.

Legal/Compliance: CMS does not specify the elements of a comprehensive care plan.
CMS suggested the following elements as typical of care plans for chronically
ill patients:

  • Problem list, expected outcome and prognosis and measurable treatment goals;
  • Symptom management, planned interventions and identity of the individuals responsible for each intervention, and medication management;
  • Community/social services ordered and a description of how direction/coordination of agency services and specialists unconnected to the CCM-billing practice will occur; and
  • Requirements for periodic revision and, when applicable, revision of the care plan.

Given that the care plan is one of the three required elements,
medical practices should be particularly diligent in the regular development
and revision of the care plan based on the documentation of CCM services, the
summary clinical record and structured recording of the patient’s chronic
condition status and treatment. MACs and other CMS contractors will likely
focus on the care plan in their audits of CCM services.

CCM Services

CMS requires the following scope of CCM services must be offered
and available to the patient:

  • Provision of 24/7 access to care management services, including a means for the patient to make timely contact with the practice’s providers to address urgent chronic care needs at any time;

Care management for the patient’s chronic conditions including:

  • Systematic assessment (monitoring) of medical, functional and psychosocial needs;
  • System-based approaches to ensure timely receipt of all recommended preventive services;
  • Medication reconciliation with review of adherence and potential interactions; and Oversight of the beneficiary’s self-management of medications;
  • Management of care transitions (specialty referrals and discharges from health care facilities) with electronic communication (other than fax) of a summary care record between and among health care providers and settings;
  • Care coordination and communication with home and community-based clinical service providers that must be electronically documented in the patient’s record;
  • Continuity of care with the designated member of the care team with whom the patient has successive, routine appointments; and
  • Enhanced opportunities for beneficiary and care team communication through telephone access and the use of secure messaging, Internet or other asynchronous non-face-to-face consultation.

Legal/Compliance: The physicians, APNs, PAs and other clinical staff providing CCM services may be employees, leased employees or independent contractors of the medical practice. Licensed or certified clinical staff may provide CCM services (check State law). The medical practice may engage third parties to provide the CCM services if there is clinical integration including documentation of how oversight and integration occur.

General Supervision Permitted

CCM services may be provided and billed directly by physicians
or OQHPs, or provided incident-to the billing professional’s services.
Typically, incident-to services are provided under the professional’s direct supervision
in order to be billed to Medicare under his provider number. CCM requirements
mandate 24/7 access to CCM services and non-face-to-face services that may
often be performed outside the office. The physician or OQHP may be unavailable
to directly supervise such services. Consequently, CMS made CCM an exception to
the incident-to rule and requires only general supervision for CCM services.
General supervision is not defined in the MPFS CCM rules. General supervision is considered to be services
“under the professional’s overall control but without his physical presence”
under other Medicare rules governing home health services.

Legal/Compliance: A medical practice written policy on general supervision is
necessary to comply with CMS’s direction that there be sufficient oversight
demonstrating ongoing participation of the professional in the patient’s care
and that CCM is being delivered as part of the prescribed course of treatment. The
physicians, APNs, PAs and other clinical staff providing CCM services may be
employees, leased employees or independent contractors of the medical practice.
Licensed or certified clinical staff may provide CCM services (check State
law). The medical practice may engage third parties to provide the CCM services
if there is clinical integration including documentation of how oversight and
integration occur.

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