Medicare to pay for chronic care management:
Eligibility and scope of CCM services
Medicare beneficiaries with at least two “chronic conditions” are eligible for CCM services if the conditions are expected to last at least 12 months or until the death of the patient, and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Beyond these somewhat abstract references, the Centers for Medicare & Medicaid Services (CMS) has not given substantial guidance to define specific conditions that qualify.
A provider must include the following scope of service elements in order to qualify for CCM service payment:
- Enhanced access. The provider must grant the patient and caregiver:
- Access to healthcare providers in the practice on a 24/7 basis to address acute chronic care needs on a timely basis, and
- Enhanced opportunities to communicate by telephone as well as secure messaging, Internet, or other asynchronous non-face-to-face methods.
- Continuity of care. The provider must give continuity of care with a designated practitioner or member of the care team for successive routine appointments.
- Care management. The provider must manage care for chronic conditions, including:
- Systematic assessment of the patient’s medical, functional, and psychological needs,
- System-based approaches to ensure timely receipt of recommended preventive care services,
- Medication reconciliation,
- Oversight of medication self-management, and
- Development and update (in consultation with the patient, caregiver, and other practitioners) of a written, patient-centered plan of care for all health issues.
- Transition management. The provider must manage “care transitions,” including:
- Referrals to healthcare professionals,
- Visits following emergency department visits and discharges from hospitals and skilled nursing facilities,
- Communications through electronic exchange of a summary care record regarding the transitions, and
- Availability of qualified personnel to deliver timely transitional care.
- Coordination. The provider must coordinate care between home and community based clinical service providers to support the patient’s psychosocial needs and functional deficits, with the communications documented in the medical record system.
Payment amounts and billing requirements
CMS has proposed a payment amount of $41.92 for providing at least 20 minutes of CCM services to a patient during a 30 day billing period. Only a single CCM payment is allowed for services to a particular beneficiary during a 30 day period. CCM payments are in addition to reimbursement under other billing codes. In order to avoid duplicate payment, however, CCM billing is not allowed for services to patients who receive services that are billed under CPT or HCPCS codes for transitional care management services, home healthcare supervision, hospice care supervision, or certain ESRD services.
Prior to furnishing or billing for CCM services, the physician or mid-level provider is required to inform the beneficiary about the services, discuss the services with the beneficiary, obtain the beneficiary’s written agreement (which the beneficiary may revoke at any time), and provide a written or electronic copy of the care plan to the beneficiary. These communications must be documented in the medical record. CMS recommends that the practitioner furnish an annual wellness visit or preventive physical exam, but this is not required.
In addition to proposing the payment rate, the 2015 Medicare Physician Fee Schedule Proposed Rule sets forth proposed policies to:
- Revise the Medicare “incident to” supervision requirement to allow general supervision (rather than the more stringent direct supervision standard in place for most services), so that services of clinical staff members providing aspects of CCM services can be counted toward the 20 minute minimum even if the practitioner is not present,
- Require use of certified electronic health record technology with an electronic care plan accessible to all providers within the practice and to care team members outside the practice, and
- Prohibit a practice from billing under CCM codes for services furnished to beneficiaries who are attributed to the practice under the Multi-payer Advanced Primary Care Practice Demonstration or the Comprehensive Primary Care Initiative (both being Medicare capitated payment pilots), as CMS views this as “duplicative” billing.
The deadline for comments to the 2015 Medicare Physician Fee Schedule Proposed Rule is 5:00 p.m. ET on Sept. 2, 2014.
Implications and action steps
The CCM policies will provide new opportunities for physicians, mid-level providers, and their medical practices to furnish coordinated care while finding new sources of revenue for services that previously did not generate reimbursement. Physicians in practice settings that are conducive to the CCM model may find that with careful structuring CCM can provide the potential to improve the health of their patients as well as financial benefits. In some practices a substantial majority of the Medicare patients could be suffering from multiple chronic conditions and therefore eligible for CCM.
The CCM program has some of the tantalizing characteristics of “forbidden fruit.” On the one hand, the CCM revenue for a medical practice (or even a single physician) can potentially be substantial. For example, a physician with 1,000 eligible patients could generate nearly $42,000 per month in CCM fees on top of his or her normal billing. On the other hand, in light of the financial temptations and the new conditions that need to be satisfied, the CCM concept appears susceptible to fraud if not carefully monitored. CCM services are therefore likely to generate close scrutiny and a corresponding need to implement effective systems to address a morass of compliance concerns. Practitioners should be mindful of the potential for second-guessing from government auditors and qui tam whistleblowers if documentation fails to clearly show satisfaction of all required standards for CCM reimbursement.
Physicians and other providers who have an interest in furnishing CCM services for Medicare beneficiaries should review the CCM scope of services and related requirements, as well as their capabilities, infrastructure, and roster of patients, to determine the feasibility of furnishing CCM services. Providing CCM services will require advance planning and investment, so it is important to allow sufficient lead time to engage and train appropriate personnel, develop infrastructure, implement policies and procedures, identify eligible beneficiaries, and take other steps to provide effective and compliant CCM services.
Open issues and concerns
The new CCM policies raise many important questions and details that await future guidance from CMS. For example:
- How will “chronic conditions” be defined? It seems reasonable to assume that CMS will issue guidance on how to determine whether a beneficiary’s conditions qualify for CCM. In the absence of clear standards, it may be difficult to proceed with confidence that determinations of patient eligibility for CCM will be respected.
- Are 24/7 access and “enhanced” provider communications now “covered services” under CMS guidelines? If so, how will this implicate hybrid fee-for-service concierge medical practices?
- To what extent can services that physicians and staff already provide count toward including the provision of at least 20 minutes of non-face-to-face management services for each CCM beneficiary, particularly if the services are related to services billed under E/M codes?
- Will CMS finalize the policy changes as proposed under the 2015 Medicare Physician Fee Schedule Proposed Rule? In particular, will general supervision of clinical staff be sufficient? What requirements will CMS impose with respect to electronic health records and related technology? Will CMS impose additional standards?
- Which provider would be entitled to CCM pay if practitioners within multiple practices are involved in furnishing potential CCM services?
To protect themselves, physicians will need to invest in technology and related infrastructure capable of offering the enhanced services and documenting them. Failure to document satisfaction of all applicable requirements would be a recipe for potential audit or false claims exposure.
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