Get Paid for What You’re Doing: Chronic Care Management Codes Kim Walter, PhD Director of Care Integration and Behavioral Health Education St. Anthony North Family Medicine

Polling Question

CPT Beginning January 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (PFS) under American Medical Association Current Procedural Terminology (CPT) code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.

CPT is defined as follows: 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 required elements:

… with the following required 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.

Examples of chronic conditions include, but are not limited to, the following: Alzheimer’s disease and related dementia; Arthritis (osteoarthritis and rheumatoid); Asthma; Atrial fibrillation; Autism spectrum disorders; ` Cancer; Chronic Obstructive Pulmonary Disease; Depression; Diabetes; Heart failure; Hypertension; Ischemic heart disease; Osteoporosis

That’s my entire Patient Population! Scope of Service Requirements Patient Agreement Requirements Billing Requirements

CCM Scope of Service Elements The CCM “practice requirements” including – Structured recording of patient health information, – Electronic care plan addressing all health issues, – Access to care management services, – Managing care transitions, – Coordinating and sharing patient information with practitioners and providers outside the practice. – Use of a certified EHR or other electronic technology.

Structured Data Recording Record the patient’s demographics, problems, medications, and medication allergies and create structured clinical summary records using certified EHR technology. – CMS requires the use of a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31st of the calendar year preceding each Medicare PFS payment year (referred to as “CCM certified technology”). For more information, search “EHR Incentive Programs” on the CMS website.

Comprehensive Care Plan ● Create a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues). ● Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record. ● Ensure the care plan is available electronically at all times to anyone within the practice providing the CCM service. ● Share the care plan electronically outside the practice as appropriate

Access to Care Ensure 24/7 access to care management services, – A means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs. Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments. Provide enhanced opportunities for the patient to communicate with the practitioner regarding the patient’s care. – Telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods, in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

Manage Care Care management services such as: 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

Manage Care Manage care transitions between and among health care providers and settings, and referrals to other providers, including: – Providing follow-up after an emergency department visit, and after discharges from hospitals, skilled nursing facilities, or other health care facilities. Coordinate care with home and community based clinical service providers.

Patient Agreement Requirements Inform the patient of the availability of the CCM service offer the CCM service to the patient Document this discussion, in the patient’s medical record, and note the patient’s decision to accept or decline the service. Billing practitioner must initiate the CCM service prior to furnishing or billing it, during a face-to-face visit (annual wellness visit, initial preventive physical exam, or comprehensive E&M visit billed separately)

Informed consent Inform the right to discontinue CCM, verbally or in writing, at any time (effective at the end of the calendar month) Inform that only one practitioner can furnish and be paid by Medicare for CCM within a service period Inform that cost sharing (co-insurance and deductibles) applies to these services; Document written informed consent

Billing Requirements At least 20 minutes of CCM services provided per calendar month. CCM should not be treated as a per member, per month payment as CCM may only be billed when a least 20 minutes of non-face-to- face care coordination services are provided. Time spent providing CCM on different days or by different clinical staff in the same month may be aggregated to total 20 minutes

Other Billing Requirements CPT code cannot be billed during the same service period as – Transitional Care Management (CPT codes 99495– ), – Home health care supervision/hospice care supervision (codes G0181/G0182) – End-Stage Renal Disease services (CPT codes 90951–90970)

Other Billing Requirements There are additional restrictions on billing for practitioners participating in a CMS sponsored model or demonstration program such as – the Multi-payer Advanced Primary Care Practice (MAPCP) – the Comprehensive Primary Care (CPC) Initiatives.

Who Can Furnish CCM Services provided directly by an appropriate physician or non- physician practitioner, or by clinical staff incident to the billing physician or non-physician practitioner, count toward the minimum amount of service time required to bill the CCM service (20 minutes per calendar month). CMS provided an exception under Medicare’s “incident to” rules that permits clinical staff to provide the CCM service incident to the services of the billing physician (or other appropriate practitioner) under the general supervision (rather than direct supervision) of a physician (or other appropriate practitioner).

Who Can Furnish CCM The program should be described by the provider and documented in the patients electronic record. The actual signing of the consent and further management of the program can be provided by office staff including medical assistants, LPNs, RNS, health coaches, and care coordinators.

Who Can Document? The supervising provider or staff working under the supervision of the provider of record. CCM interactions must follow the patient’s care plan.

How do I get paid? Document at least 20 minutes of clinical staff time for the calendar month Bill using CPT ® code Bill only once per calendar month Collect any deductible or coinsurance from the patient Remember the exceptions

How much do I get paid?

2 patients/day x 5 days/week x 4 weeks/month = 40 patients per month 40 patients per month x $43.28 = $1, per month = $20, per year 100 patients per month (25/week or 5/day) = $4,328 per month = $51, 936 per year

Does this Apply to Your Practice? Audience Questions: – What work are you currently doing that meets criteria for CCM? – How could CCM codes advance your current care management model?

Review CPT code is for non face-to-face care management/coordination; Beneficiaries with 2 or more chronic conditions Billed once per calendar month that a minimum of 20 min of qualifying care is provided Transitional Care Management (TCM) and other overlapping care management services cannot be billed during the same service period Pays about $43 and standard coinsurance applies

ResourceWebsite CCM Frequently Asked Questions (FAQs) Medicare-Fee-for-Service-Payment/ PhysicianFeeSched Fact SheetMedicare Learning Network® “Chronic Care Management Services” Fact Sheet Education/Medicare-Learning- NetworkMLN/MLNProducts/Downloads/C hronicCareManagement.pdf Education/Medicare-Learning- NetworkMLN/MLNProducts/Downloads/C hronicCareManagement.pdf Final Rules in the Federal Register (policies governing CCM services) CY 2015 Medicare PFS Final Rule (CMS FC): /pdf/ pdf /pdf/ pdf CY 2015 Medicare PFS Final Rule; Correction Amendment (CMS-1612-F2): /pdf/ pdf /pdf/ pdf

Audience Contribution Share your knowledge and payment secrets!

Kim Walter, PhD Director of Care Integration and Behavioral Health Education St. Anthony North Family Medicine