1. CHRONIC CARE MANAGEMENT CODE 99490 CMMI July 2015
Draft as of 7/15

2. 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

3. 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 (2015)
Draft as of 7/15

4. 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%)
Patients cannot reside in a facility that receives Medicare Facility payment (SNF)
High-risk,
Complex,
Frail elderly
Draft as of 7/15

5. 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 (
Draft as of 7/15

6. 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 , portal. 24/7 access can contract with a third party to provide non-face-to-face care management services. Electronic transmission to providers (secure 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Sources
CY 2015 Medicare PFS Final Rule:
Medicare Learning network MLN/MLNProducts/Downloads/ChronicCareManagement.pdf
Updated MLN Fact sheet “Frequently Asked Questions about Billing Medicare for Chronic Care Management Services”
PYA White Paper
PYA Webinar
ACP Toolkit
BizMed
Family Practice Medicine Blog
“Nation's sickest seniors reshape health care” – USA Today.com
Draft as of 7/15

14.
Draft as of 7/15