CHRONIC CARE MANAGEMENT CODE 99490 CMMI July 2015 Draft as of 7/15 www.flhsa.org

Chronic Care Management (CCM) What is Chronic Care Management 99490? Who can Participate? What are the Requirements and Services? What is Necessary to set up CCM Program? Draft as of 7/15 www.flhsa.org

Support of primary care Care management Background Support of primary care Care management Reduce Hospital Readmissions - Transitional Care Management (2013) Value of “non-face-to face” resources for high risk Medicare beneficiaries - Chronic Care Management code 99490 (2015) Draft as of 7/15 www.flhsa.org

CCM Code Defined 20 min At least 20 minutes of clinical staff time directed by a physician or qualified health care professional each calendar month that is reimbursed at ~$42 per patient. (non-face-to-face) Patients FFS Medicare patients and Medicare Advantage patients 2 or more chronic conditions Expected to last at least 12 months or until the death of the patient Chronic conditions that place the patient at significant risk of death or acute exacerbation/decompensation or functional decline Chronic conditions have been identified in the Chronic Condition Warehouse (CCW) This is not an exhaustive list, other conditions can be included that place the patient at high risk Most common Hypertension (58%) High Cholesterol (45%) Heart Disease (31%) Arthritis (29%) Diabetes (28%) 4. Patients cannot reside in a facility that receives Medicare Facility payment (SNF) High-risk, Complex, Frail elderly Draft as of 7/15 www.flhsa.org

Eligible Practices Who Can Bill Who Cannot Bill Certified EHR 2011 or 2014 Physician, Advance Practice Provider (APP) Practices affiliated with an ACO Who Cannot Bill Rural Health Centers (RHC) and Federally Qualified Health Center (FQHC) Rule change for 2016 Who Can Provide Services (Non-face-to-face) In addition to the physician, licensed clinical staff (APP, RN, LCSW, LPN) can provide services under general supervision Decision whether to use Medical Assistants Practice will need to meet EHR certification criteria acceptable for incentive payment as of 12/31, for each calendar year preceding CCM payment Physicians can be of any specialty, whoever bills first gets paid first Not required to be a Patient Centered Medical Home To research whether to use Medical assistants: (“Frequently asked questions about billing - Medicare for Chronic Care Management Services” CPT code for definition of clinical staff Medicare Benefit Policy Manual, Chapter 15 - Transmittal Section 60.1B. Direct supervision NYSED Office of Professions (http://www.op.nysed.gov/prof/med/medmedicalassistants.htm) Draft as of 7/15 www.flhsa.org

Required Practice Capabilities EHR Structured Data Recording Document consent and care plan given to patient Communication with other providers/services Electronic Care Plan remotely accessible Patient Access 24/7 and enhanced communication Continuity of Care – Designated member of care team Systematic assessment of health needs/preventive services (i.e. population health management, gap work, pre-visit planning) Manage transitions between and among providers 1st capability: Must document in EHR that consent and care plan were given to patients and any communication with providers. 2nd capability: Patient communication phone, secure email, portal. 24/7 access can contract with a third party to provide non-face-to-face care management services. Electronic transmission to providers (secure email okay). 3rd capability: Continuity of care – successive appointments with practitioner. 4th capability: ~ PCMH, ensure timely receipt of preventive services. 5th capability: Care coordination including transitions (e.g., referrals, discharge from ED, discharge urgent care are billable.) Draft as of 7/15 www.flhsa.org

Chronic Care Management Care Plan CMS does not provide a definition Created based on AWV, IPPE, or Comprehensive visit Based on a comprehensive systematic health assessment (~PCMH) Electronically accessible to CCM team (24X7) and transmittable to other care providers Provide copy in writing or electronic to patient Updates regularly Not required to be part of the EHR. Covers all health issues on problem list. Can bill CCM for updating the electronic care plan as part of 20 minutes… as long as clinical staff are doing that activity and it is not part of the visit. Contents of care plan Expected outcomes and prognosis, measurable treatment goals Symptom management Planned interventions /who is responsible for intervention Medication management Community/social services ordered Inventory of resources and supports and how coordinated Patients Preferences and values Draft as of 7/15 www.flhsa.org

Signed consent includes Informed Consent Signed consent includes What are the services How the services will be delivered How to revoke, transfer services Authorization for electronic communication of medical information Designated provider/practitioner Patient copay or other deductible for services One time only unless someone else is going to bill Patient receives copy written or electronic Beneficiaries who agree to participate and sign an agreement that requires them to pay a coinsurance or deductible. Ask patient if any other specialists have asked for consent. Recommend that a practitioner furnish an Annual Wellness Visit or Initial Preventive Physical Examination prior to furnishing billing CCM. Consent occurs at a face-to-face visit. Consent is not billable under 99490, it is billed under the visit. Request patient revoke in writing. Draft as of 7/15 www.flhsa.org

Assessing Capability – Part 1 Analysis Do you have the resources to implement the program in addition to your day-to day-work? 24/7 access Necessary equipment What activities are your clinical staff already doing that are CCM? How much time to track work? Bill what you are already doing! Draft as of 7/15 www.flhsa.org

Assessing Capability – Part 2 Return on Investment Criteria for selecting patients Number of eligible patients 2 + chronic conditions Likely to consent Return on Investment Discussion and Debrief This is based on 100% of your CCM patients are billed 20 minutes each calendar month for twelve months CCM patients pay their coinsurance, copay or deductible. Draft as of 7/15 www.flhsa.org

See Role Based Workflow Handout for outline Project Plan Set Up Create tools Workflow/Roles Training Pilot Small Group Identify eligible patients with the same two conditions Identify practitioner and care team Obtain and document consent Primary practitioner develops care plan Track and bill services Audit process Tools (Patient log, consent, care plan, tracking document) Log (Patient name, date, accept or deny, revoke/death) Track time (patient name, date, billing practitioner, start stop time, describe activities) When to bill See Role Based Workflow Handout for outline Draft as of 7/15 www.flhsa.org

Informed Consent - Discussion See examples of consents and talking points In your groups discuss the following: Which consent might you use? How have you/do you plan to have this discussion with your patients? Who will have the discussion with patients? What key points will you highlight? Debrief Handouts include: ACP (American College of Physicians) Toolkit Consent Form PYA (Pershing and Young Associates) Consent Form Sample Talking points Draft as of 7/15 www.flhsa.org

Sources CY 2015 Medicare PFS Final Rule: http://www.gpo.gov/fdsys/pkg/FR-2014-11-13/pdf/2014-26183.pdf Medicare Learning network http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ChronicCareManagement.pdf Updated MLN Fact sheet “Frequently Asked Questions about Billing Medicare for Chronic Care Management Services” www.cms.gov/.../2015-02-18-Chronic-Care-Management-new.html PYA White Paper http://www.pyapc.com/resources/collateral/white-papers/Chronic-Care-Whitepaper-PYA.pdf PYA Webinar http://www.slideshare.net/PYAPC/providing-and-billing-medicare-for-transitional-and-chronic-care-management ACP Toolkit http://www.acponline.org/running_practice/payment_coding/medicare/chronic_care_management_toolkit.pdf BizMed https://www.bizmedtoolbox.com/Documentation/Library/5/2015013011333871820150130113338718Default.pdf Family Practice Medicine Blog http://blogs.aafp.org/fpm/gettingpaid/entry/chronic_care_management_lots_of “Nation's sickest seniors reshape health care” – USA Today.com http://www.usatoday.com/story/news/2015/06/05/medicare-costs-seniors-sick-chronic-conditions/27390925/ Draft as of 7/15 www.flhsa.org

www.flhsa.org Draft as of 7/15