Chronic Care Management: Inquiring Minds Want To Know – Part 1

Martie RossBy Martie Ross

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.

Also, we have recently published an article on transitional and chronic care management from a coder’s perspective.

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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.

Questions 6-10 of this series (Part 2) are available here.