Complex Chronic Care Management - Detailed Description

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Physicians participating in one of the following CMS models/demonstration programs cannot bill chronic care management (CCM) services for Medicare beneficiaries participating in the program; however, when appropriate, the practice can bill CCM services provided to Medicare beneficiaries who chose not to participate in the program:

  • Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration
  • Comprehensive Primary Care (CPC).

Information in this article has been researched and checked for validity, accuracy, and completeness based on the information available. Newby Consulting Inc. (NCI) uses reasonable efforts to provide accurate and up-to-date information; however, NCI accepts no responsibility or liability with regard to errors, omissions, misuse, or misinterpretations in the content of this article. NCI does not make any warranties or representations as to the accuracy or completeness of such information. The User's use thereof shall constitute an agreement by the User to release NCI and its employees from any liability for the content of this article, or for the consequences of any actions taken on the basis of the information provided.

The information included in this article should not be construed as an official source that includes all the details and criteria for reporting CCM services. This article is based on the following three (3) references:

  • Federal Register 11/13/2014 – Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015 Final Rule
  • Federal Register 12/10/2013 – Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014 – Final Rule
  • American Medical Association’s CPT and RBRVS 2015 Annual Symposium – 11/19/2014 – Presentation by Kathy Bryant, Director, Division of Practitioner Services, CMS

There are two sets of codes for chronic care management in CPT® 2015:

Chronic Care Management Services – Use this code to report 99490 when all applicable criteria have been met:

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 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
    • Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately

Complex Chronic Care Management Services – These codes are bundled and not separately billable to Medicare or a Medicare beneficiary

99487 
Complex chronic care management services, with the following requirements:

  • 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 significant 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
    • Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not separately reported

+99489
Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure [99487]

  • Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex chronic care management services during a calendar month

Payment for CCM does not include a face-to-face component. Physicians will separately report any evaluation and management (E/M) services using the appropriate level of care code to describe any face-to-face encounter that occurs during the calendar month.

Caveat: You cannot count the clinical staff’s time related to the face-to-face E/M when determining whether at least 20 minutes of CCM was provided to the Medicare beneficiary.

 CPT coding notes clearly state that providers cannot report both TCM and CCM for the same calendar month.

 “If care management resumes after a discharge during a new month, start a new period or report transitional care management. If discharge occurs in the same month, continue the reporting period OR report TCM.”

When CCM criteria are met for a given month, the practice must report CPT code 99490. The 2015 Indiana Medicare Fee Schedule for 99490 for dates of service 1/1/2015 through 3/31/2015 is $40.52!

Ms. Bryant explained that when the criteria for reporting 99490 is met (including at least 20 minutes of clinical staff time during the calendar month), the CCM code should be reported on the last day of the calendar month regardless of whether that date falls on a weekend or holiday.

CCM criteria

  • Eligible Beneficiaries must have
  • 2 or more chronic conditions
    • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
    • Expected to last more than one year or until the death of the patient
  • After the required disclosure and obtaining a signed agreement, beneficiary elects to participate in CCM services (see below)

  • Elements of CCM Scope of Service
    • Recording of structured data
    • Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record. A full list of problems, medications and medication allergies in the EHR must inform [sic] the care plan, care coordination and ongoing clinical care
      • Must use EHR certified technology.
  • Patient access, 24 hours a day, 7 days a week
    • The patient must be provided with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week
    • May be performed by clinical staff without direct physician/other qualified healthcare professional – Incident to exception for CCM (also applicable to transitional care management services)
  • Continuity of care with specified member of team
    • Designated practitioner or member of the care team with whom the patient is able to get successive routine appointments
  • Care management for chronic conditions
    • Includes systematic assessment of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medication
  • Management of transitions, including referrals
    • Practitioner (physician OR other qualified healthcare professional) furnishing CCM services must create and document a patient-centered care plan to assure that care is provided in a way that is congruent with patient choices and values. The care plan is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports.

It is a comprehensive plan of care for all health issues, and typically includes, but is not limited to, the following elements:

  • problem list
  • expected outcome and prognosis
  • measurable treatment goals
  • symptom management
  • planned interventions
  • medication management
  • community/social services ordered
  • how the services of agencies and specialists unconnected to the billing practice will be directed/coordinated
  • identify the individuals responsible for each intervention
  • requirements for periodic review and, when applicable,
  • revision of the care plan.
  • A full list of problems, medications and medication allergies in the EHR must inform [sic] the care plan, care coordination and ongoing clinical care
  • Must at least electronically capture care plan information; make this information available on a 24/7 basis to all practitioners within the practice whose time counts towards the time requirement for the practice to bill the CCM code; and share care plan information electronically (other than by fax) as appropriate with other practitioners and providers.
    • Provide the beneficiary with a written or electronic copy of the care plan and document its provision in the electronic medical record.
    • Document provision of the care plan as required to the beneficiary in the EHR using CCM certified technology.
  • Coordination with home and community based clinical service providers required to support a patient’s psychosocial needs & functional deficits
    • Communication to and from home and community based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record using CCM certified technology
  • Enhanced opportunities for patient communicate, including through secure messaging, Internet, etc.

  • In addition to meeting the above criteria as applicable, in order to bill Medicare for the above CCM service
  • Practitioner must inform the beneficiary and obtain written agreement – Need to create required written agreement with disclosure
    • Inform the beneficiary about the availability of the CCM services from the practitioner and obtain his or her written agreement to have the services provided, including the beneficiary’s authorization for the electronic communication of the patient’s medical information with other treating providers as part of care coordination.
    • Document in the beneficiary’s medical record that all elements of the CCM service were explained and offered to the beneficiary, and note the beneficiary’s decision to accept or decline the service.
    • Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of a calendar month) and the effect of a revocation of the agreement to receive CCM services.
    • Inform the beneficiary that only one practitioner can furnish and be paid for these services during the calendar month service period.

NCI recommends explaining to the beneficiary that Medicare does not pay 100 percent of the charges for CCM services. The beneficiary is responsible for any deductible as well as the 20 percent coinsurance amount.

Medicare “Incident to Billing” for CCM Services

Under the current “incident to” billing criteria, services and supplies must be furnished under the direct supervision of the physician (or other qualified health care professional). Direct supervision is defined at 42 CFR §410.32(b)(3)(ii):

Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

CMS has made a narrow exception to this “incident to” billing requirement for CCM and TCM services in 42 CFR §410.26 (a)(5).

In general, services and supplies must be furnished under the direct supervision of the physician (or other practitioner). Services and supplies furnished incident to transitional care management and chronic care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided by clinical staff. The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) upon whose professional service the incident to service is based.

General supervision is defined at 42 CFR §410.32(3)(i)

General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician

Auxiliary personnel is defined at 42 CFR (a) Definitions

(1) Auxiliary personnel means any individual who is acting under the supervision of a physician (or other practitioner), regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or other practitioner) or of the same entity that employs or contracts with the physician (or other practitioner) and meets any applicable requirements to provide the services, including licensure, imposed by the State in which the services are being furnished.

(3) Independent contractor means an individual (or an entity that has hired such an individual) who performs part-time or full-time work for which the individual (or the entity that has hired such an individual) receives an IRS-1099 form.

(4) Leased employment means an employment relationship that is recognized by applicable State law and that is established by two employers by a contract such that one employer hires the services of an employee of the other employer.

NCI Comment: At this time, we are not able to find any instructions for determining who should be identified as the supervising (Items 17/17b) and rendering provider (Item 24j) on the claim for CCM services. It seems reasonable that the physician/other qualified healthcare professional who has the primary responsibility for developing and revising the care plan should be entered as both the supervising and rendering on the claim.’

Until formal instructions are issued, it is left to the practice to determine who should be entered in Items 17/17b and 24j.

CPT codes and two-digit modifiers are copyright 2013, American Medical Association