Wednesday, August 5, 2015

Chronic Care Management Q & A

Medicare "Ask-the-Contractor" teleconference (ACT): Chronic Care Management

Chonic 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:

• Multiple (two or more) chronic conditions expected to last 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

Two weeks after this webcast, CMS produced a special edition article (SE1516) titled “Chronic Care Management (CCM) Services Frequently Asked Questions (FAQs)” that addressed and clarified many of the questions asked during the webcast, including some that were not answered at that time. Below we have provided a breakdown of the questions and answers, with links provided to documents addressing these topics.

Q1. Can CCM services be provided by clinical staff external to the practice?
A1. A billing physician (or other appropriate practitioner) may arrange to have CCM services provided by clinical staff external to the practice (for example, in a case management company) if all of the “incident to” and other rules for billing CCM to the physician fee schedule (PFS) are met. Because there is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 Code of Federal Regulations 411.9), CCM services cannot be billed if they are provided to patients or by individuals located outside of the United States.

Q2. How often is a new consent form required from the patient?
A2. As provided in the CY 2014 PFS final rule (78 Federal Register [FR] 74424), a new consent is only required if the patient changes billing practitioners, in which case a new consent must be obtained and documented by the new billing practitioner prior to furnishing the service.

Q3. What date of service should be used on the claim, and when should the claim be submitted?
A3. The service period for current procedural terminology (CPT) 99490 is one calendar month, and CMS expects the billing practitioner to continue furnishing services during a given month as applicable after the 20 minute time threshold to bill the service is met. However practitioners may bill the PFS at the conclusion of the service period or after completion of at least 20 minutes of qualifying services for the service period. When the 20 minute threshold to bill is met, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month.

Q4. What if the patient is in a hospital or skilled nursing facility (SNF)?
A4. If the patient resides in a community setting and the CCM service is provided by or “incident to” services of the billing physician (or other appropriate billing practitioner) working in or employed by a hospital, CPT 99490 can be billed to the PFS and payment is made at the facility rate (if all other billing requirements are met).
Addressed in the calendar year (CY) 2014 PFS final rule, the resources required to provide care management services to patients in facility settings significantly overlap with care management activities by facility staff that are included in the associated facility payment. Therefore, CPT 99490 cannot be billed to the PFS for patients who reside in a facility (that receives payment from Medicare for care of that beneficiary, see 78 FR 74423) regardless of the location of the billing practitioner, because the payment made to the facility under other payment systems includes care management and coordination. For example, CPT code 99490 cannot be billed to the PFS for services provided to SNF inpatients or hospital inpatients, because the facility is being paid for extensive care planning and care coordination services. However if the patient is not an inpatient the entire month, time that is spent furnishing CCM services to the patient while they are not inpatient can be counted towards the minimum 20 minutes of service time that is required to bill for that month.
Billing practitioners in hospital-owned outpatient practices that are not provider-based departments are working in a non-facility setting, and may therefore bill CPT 99490 and be paid under the PFS at the non-facility rate. However, CPT 99490 can only be billed for CCM services furnished to a patient who is not a hospital or SNF inpatient and does not reside in a facility that receives payment from Medicare for that beneficiary.

Q5. Are there CCM scenarios in which the physician does not need to see the patient face-to-face?
A5. No, as provided in the CY 2014 final rule (78 FR 74425), CCM must be initiated by the billing practitioner during a comprehensive Evaluation & Management (E/M) visit, annual wellness visit (AWV) or initial preventive physical exam (IPPE). This face-to-face visit is not part of the CCM service and can be separately billed to the PFS, but is required before CCM services can be provided directly or under other arrangements. The billing practitioner must discuss CCM with the patient at this visit. While informed patient consent does not have to be obtained during this visit, it is an opportunity to obtain the required consent. The face-to-face visit included in transitional care management (TCM) services (CPT 99495 and 99496) qualifies as a comprehensive visit for CCM initiation. CPT codes that do not involve a face-to-face visit by the billing practitioner or are not payable by Medicare (such as CPT 99211, anticoagulant management, online services, telephone and other E/M services) do not meet the requirement for the visit that must occur before CCM services are furnished. If the practitioner furnishes a comprehensive E/M, AWV, or IPPE and does not discuss CCM with the patient at that visit, that visit cannot count as the initiating visit for CCM.

Q6. What place of service (POS) should be reported on the physician claim?
A6. Practitioners must report the POS for the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient). Accordingly, practitioners who furnish CCM in the hospital outpatient setting, including provider-based locations, must report the appropriate POS for the hospital outpatient setting). Payment for CCM furnished and billed by a practitioner in a facility setting will trigger PFS payment at the facility rate.

Q7. Can CCM services be billed by a provider when another provider is billing home health services?
A7. No. Under no circumstance may home health care or hospice care supervision codes (G0181/G0182) and chronic care management (code 99490) be billed/paid in the same month, as these services would be overlapping. This is not dependent on the provider: if these services are being provided, chronic are management would be overlapping with these services, and thus not paid separately in the same month.

Q8. Does the time to develop a care plan count towards fulfillment of the 20 minutes required for CCM services?
A8. CCM services can only be billed/paid after a patient has been seen by the provider during an AWV, an IPPE, or a comprehensive E/M visit. This visit would involve identification of and arrangement for CCM in future months (with fulfillment of CCM requirements). The time involved in this initial planning and arrangement for CCM would not be counted for CCM – this planning/arrangement would be included as part of that initial evaluation and management service. Under longstanding Medicare guidance, only one E/M service can be billed per day unless the conditions are met for use of modifier -25. Time cannot be counted twice, whether it is face-to-face or non-face-to-face time, and Medicare and CPT specify certain codes that cannot be billed for the same service period as CPT 99490. Face-to-face time that would otherwise be considered part of the E/M service that was furnished cannot be counted towards CPT 99490. Time spent by clinical staff providing non-face-to-face services within the scope of the CCM service can be counted towards CPT 99490. If both an E/M and the CCM code are billed on the same day, modifier -25 must be reported on the CCM claim. Over the ensuing months, as CCM is provided, the care plan might change, and time taken for this attention to the care plan may be counted as CCM.

Q9. How can we identify what is meant by “chronic condition”?
A9. CMS has created a website titled “Chronic Conditions Data Warehouse” to assist in identifying chronic conditions.

Q10. Can more than one practitioner be paid for CCM services (i.e., separate specialists)?
A10. No, under the PFS only one practitioner may be paid for the CCM service for a given calendar month.

Q11. Will complex chronic care management codes (99487 and 99489) now be paid?
A11. No, these codes will continue to be bundled under the PFS and not be paid separately.

Q12. Can specialists bill for CCM?
A12. The CCM service may be billed most frequently by primary care physicians, although specialty physicians who meet all of the billing requirements may bill the service.

Q13. How will CCM impact provider billing/payment?
A13. First Coast’s data analysis reveals that providers are improperly billing this service. In response to these findings, First Coast will be implementing edits within the claim processing system to avoid improper payment for CCM services that do not meet CCM service guidelines.

Q14. Which practitioners must have access to the electronic record that applies to the CCM?
A14. The electronic record must be accessible to all practitioners within the practice whose time will count toward fulfilling CCM requirements.

Q15. For how long may CCM services be provided to a patient?
A15. There is no limit to the number of months that a patient may receive CCM services.

Q16. What form should be used when obtaining patient consent for CCM?
A16. Currently CMS has not specified a form or template that must be used.

Q17. Is there a requirement relating to updating the patient’s plan of care or sending this plan of care to the patient based on CCM guidelines?
A17. Based on CCM requirements, there is no specific change relating to documentation of the patient’s plan of care. The provision of CCM includes the establishment, implementation, revision and/or monitoring of a comprehensive care plan.

Q18. Can the CCM time be accumulated throughout the month based on services from separate practitioners?
A18. Yes, the 20 minutes of service to fulfill CCM monthly requirements may be cumulative among separate practitioners within the same group, however only one practitioner may be paid for the CCM service for a given calendar month.

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