Chronic Care Management: Clinical Case Linda V. DeCherrie, MD Director, Mount Sinai Visiting Doctors Program Associate Professor – Department of Geriatrics and Palliative Medicine

Faculty Disclosures DeCherrie – no relevant disclosures

Objectives Use the information presented to improve their care planning practices.

Clinical Case 76 yo woman with : Osteoarthritis H/o CVA 3 years ago Vitamin D deficiency Endometrial cancer s/p resection Depression MALT lymphoma CHF Mild cognitive impairment Homebound because of ambulation issues and was referred to program 1 year ago by resident

Clinical Case Multiple clinical issues: Falls Needing more support in the home Identifying a health care proxy and goals of care Medication management Transportation to her GI for follow up of MALT lymphoma Electric wheelchair broken

Care Team at Mount Sinai Visiting Doctors Physicians Nurse practitioners Nurses Social work Administrative assistants

Chronic Care Management (CCM) New CPT code in 2015 – Non face-to-face Care management Approximately $43 with standard co-insurance applies; $90 for hospital-based practices

CCM Requirement – Overview Applies to Medicare Fee-for-Service Program Beneficiaries with 2 or more chronic conditions 20 minutes of qualifying time Only one practitioner can bill per month Transitional Care Management, Care Plan Oversight and certain ESRD services payments cannot be billed the same month

CCM Beneficiary Medicare Fee-For-Service Consent to the services 2 or more chronic conditions expected to last at least 12 months or till death Conditions place beneficiary at risk of death, acute exacerbation/decompensation or functional decline

Back to Clinical Case Program ready to start billing CCM March 2015 (consent form through vetting process/translated and EMR and billing software ready) Consented patient in April 2015

Social Worker Met with patient multiple times in person (not CCM) and telephonically: Work on transportation issues Arrange patient to change managed medicaid to a plan where she could get her wheel chair fixed Identify family members Worked with NP for patient to identify GOC and HCP Applied for more hours of an aide at home with patient

Nurse Practitioner Met with patient multiple times in person (not CCM) and telephonically: Multiple calls with home health (RN and PT) for falls and medication issues Helped identify GOC and HCP with SW Proactive calls to patient to see progress with treatment plans

Nurse Office based telephone triage: Took many urgent calls for falls and other issues from patient

Billing May – December – billed CCM 4/7 months

Challenges with CCM Billing Practice/provider/team education Obtaining consent from patients Co-pay related to Non face-to-face encounter Recording/Tracking time for all encounters

Discussion Go to: 2Shoesapp.com/AAHCM20162Shoesapp.com/AAHCM Click on the session you are in 2.Ask and vote on questions