On February 18, the Centers for Medicare & Medicaid Services (CMS) sponsored a National Provider Call (NPC) on Medicare reimbursement for chronic care management (CCM). The NPC was the first formal presentation CMS has made regarding CCM since it began paying for this service January 1, 2015. In conjunction with the NPC, CMS also released a Medicare Learning Network Fact Sheet on CCM.
While CMS now has provided clarification on several important points, there still remain some lingering questions that will require further attention from the agency. Having now fielded hundreds of inquiries regarding CCM, PYA has compiled the following Top Ten list of CCM questions, along with the best answers we can offer at this time.
If you would like a more comprehensive explanation of CCM, please refer to our white paper, Providing and Billing Medicare for Chronic Care Management.
1. What is required to initiate CCM services?
In its rulemaking, CMS had proposed that a practitioner must furnish an annual wellness visit (AWV) or an initial preventive physical examination (IPPE) for a beneficiary within the last 12 months to bill CCM for that beneficiary. CMS, however, chose a different approach in the 2014 Medicare Physician Fee Schedule Final Rule:
However, in light of the widespread concerns raised by commenters about this requirement, we have changed the requirement to a recommendation for a practitioner to furnish an AWV or IPPE to a beneficiary prior to billing for chronic care management services furnished to that same beneficiary.
78 Fed. Reg. 74425 (Dec. 10, 2013) (emphasis added).
CMS’ recent guidance, however, is not consistent on this point. According to the Fact Sheet, “CMS requires the billing practitioner to furnish an [AWV], [IPPE], or comprehensive evaluation and management visit to the patient prior to billing the CCM service, and to initiate the CCM service as part of this exam/visit.” Also, during the NPC discussion of the informed consent requirement, the CMS representative stated the provider must “initiate the CCM service...during a face-to-face visit.”
As a technical matter, the statement made by CMS in the rulemaking process trumps the agency’s subsequent guidance. When we asked the CMS representative who presented the NPC about this apparent contradiction, she advised us to communicate with the Medicare Administrative Contractor (MAC).
Thus, at present, it is not clear exactly what is required to initiate CCM; hopefully, CMS will provide clarification soon. As a practical matter, however, we believe CCM services will be more effective if the service is initiated – and the beneficiary’s written consent is obtained - as part of a face-to-face visit. Keep in mind that such a face-to-face visit would be separately billable from the CCM.
2. Can a physician practicing in a hospital outpatient department bill for CCM? Can the hospital charge a facility fee associated with CCM? (updated on 3/2/15)
CMS has clarified that a physician practicing in a hospital outpatient department who bills for CCM will be paid at the facility rate, which is approximately $9.00 less than the non-facility rate (i.e., the payment made to a physician practicing in an outpatient office setting). The payment to the physician reimburses him or her for supervision of hospital staff furnishing the non-face-to-face care management services, as well as any care management services furnished directly by the physician himself or herself. CMS also has clarified that a hospital may bill a separate facility fee for CCM. This payment reimburses the hospital for the costs associated with the licensed clinical staff furnishing the non-face-to-face care management services and related expenses.
3. Are there circumstances in which time spent providing non-face-to-face care management services cannot be counted toward the 20-minute requirement?
CMS stated in the rulemaking process that time spent while the patient is in an inpatient setting cannot be counted. In its general discussion of care management services, the CPT Manual states non-face-to-face care management services furnished the same day as an E/M visit cannot be counted. CMS has not specifically recognized this rule, although the CPT Manual generally is considered authoritative unless contradicted by CMS. Thus, unless the same-day non-face-to-face service is wholly unrelated to the E/M visit, it should not be counted.
4. To what information must the care team have access on a 24/7 basis?
This is another example of an inconsistency between CMS’ recent guidance with its statements in the rulemaking process. The Fact Sheet states the beneficiary’s entire medical record must be accessible 24/7 to those members of the care team providing CCM service after hours. However, CMS stated in the rulemaking that only the electronic care plan must be accessible. See 79 Fed. Reg. 67722 (Nov. 13, 2014). In this case, the CMS representative who presented the NPC acknowledged this inconsistency, and indicated the Fact Sheet would be revised to refer to the electronic care plan.
5. Can Medicare Shared Savings Program (MSSP) participants bill for CCM?
Participants in CMS’ Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration and the Comprehensive Primary Care (CPC) Initiative cannot bill CCM for those beneficiaries who have been attributed to them for purposes of these programs. Otherwise, participation in other CMS’ initiatives – including the MSSP – does not disqualify a practitioner from billing CCM for any beneficiary.
6. When filing a claim for CCM, what should be listed as the date of service? As the site of service? As the relevant diagnosis?
CMS has stated that there are no claims edits in place for date of service, site of service or diagnosis codes, and thus CCM claims will not be denied based on the information listed for these items. As a practical matter, we recommend the date of service be the date on which the 20-minute requirement is satisfied, the site of service be listed as the practitioner’s primary practice location, and that at least two of the beneficiary’s chronic conditions be listed as the diagnosis codes. Note: When listing the site of service, ensure that the location selected is associated with the practitioner in Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to avoid unnecessary claims issues.
7. When should a claim for CCM be submitted?
Again, CMS has not provided guidance on this point, but we believe it is appropriate to submit the claim any time after the 20-minute requirement has been satisfied for that calendar month.
8. How should the subjective acuity test be applied?
To be eligible for CCM, a beneficiary must have two or more chronic conditions (the objective condition test) expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline (the subjective acuity test).
During the NPC, the CMS representative noted that two-thirds of Medicare beneficiaries have two or more chronic conditions, and explained that CCM was intended to reach as many of these beneficiaries as possible. It seems, therefore, the subjective acuity test was not intended to restrict access to CCM; instead, it was intended to identify those beneficiaries who would benefit from 20 minutes of care management services. So long as legitimate and beneficial non-face-to-face services are being furnished to the beneficiary, the subjective acuity test should not otherwise limit access to this care.
9. Who is qualified to provide non-face-to-face care management services?
To be counted, non-face-to-face care management services must be performed by licensed clinical staff under the general supervision of a physician. This includes any person with a state-issued license in a healthcare profession, as well as medical assistants credentialed by a third-party organization. Regardless of licensure or credentials, no person should provide any service beyond his or her training and competency.
10. What does it mean to electronically capture care plan information?
The electronic care plan – one of the key requirements for billing CCM – must be maintained in electronic format. The plan must be available on a 24/7 basis (by means other than facsimile) to members of the care team, and the provider must be capable of transmitting the plan (by means other than facsimile) to other providers involved in the patient’s care. Also, the provider must furnish an electronic or paper copy of the care plan to the beneficiary.
The plan does not have to be generated using a certified electronic health record, nor does it have to be maintained in an EHR. The information in the care plan may come from paper documents (such as a questionnaire completed by the beneficiary), but this information must be incorporated into the electronic document.
During the NPC, the CMS representative emphasized these were the care plan rules for 2015, implying that CMS is contemplating tightening these requirements in 2016. However, the representative gave no indication as to what CMS is intending to pursue.