Chronic Care Management: Making Sense of It All

Marissa Rogers, DO Genesys Regional Medical Center

Goals/ObjectivesIdentify what Chronic Care Management Services are and if/when to utilize them in your practice

Familiarize the learner with CMS requirements prior to implementation of CCM plans and requirements once the plan is in place

Identify scope of practice for CCM services

Provide important take away notes that are unique to CCM Services

What are Chronic Care Management Services?

Starting in 2015, Medicare began paying separately for non-face-to-face coordination services

Medicare Fee For Service ONLY (original Medicare)

CMS recognizes care management as a critical component of primary care, resulting in better health outcomes and reduced healthcare spending

Who is Eligible for Chronic Care Management?

Patients with 2 or more chronic conditions that are expected to last at least 12 months, OR until the death of the patient

Chronic Conditions put patient at significant risk of death, acute exacerbation/decline, or functional decline

Comprehensive Care Plan established, implemented, revised, or monitored

Conditions may include, but are not limited to Alzheimers and related dementia

Arthritis (OA/RA)

Asthma

A-Fib

Autism Spectrum Disorders

Cancer

COPD

Depression

DM

Heart Failure

HTN

Ischemic Heart Disease

Osteoporosis

What is Required of the Clinician or Clinical Staff?

At least 20 MINUTES of documented clinical staff time per MONTH, directed by the Physician or other qualified healthcare professional

CPT Code 99490

This can be billed by ONLY ONE clinician per month

Who Can Bill for CCM?Eligible Practitioners include:

Physicians

Certified Nurse Midwives

Clinical Nurse Specialists

Nurse Practitioners

Physician Assistants

Who is Considered Clinical Staff?

APRN (Advanced Practice Registered Nurse)

LPN

Certified MA

PA

Clinical Pharmacists

LSCSW

RN

Important Note on Clinical Staff

To be considered ‘Clinical Staff’, they must be:

Employed by the clinician (or practice), or contracted third party

All CCM Services MUST be generally supervised by the clinician, whether provided during or after hours

Requirements cont…

The Billing Practitioner must complete ONE of the following prior to billing CCM code and initiates CCM plan at time of visit/exam

Comprehensive E/M visit

Annual Wellness Visit

Initial Preventative Physical Exam (IPPE)

Case 68 year old female, S.J., comes in for her Annual Medicare Wellness Exam

You note that her Active Problem List includes:

DM 2, insulin dependent

HTN

Depression/Anxiety

OA of her R knee

Is Your Patient Eligible???

Your front office staff points out to you that this patient has Medicare Fee for Service …because they know you are trying to provide CCM Services to your patient population

YES! She would be a great

patient for CCM Services…but NOW

WHAT????!!

The Hard Part…

Implementing the CCM Plan can get a little complex at this stage

There are a few things you need in place PRIOR to implementation in your practice

First…Decide who will be primarily handling the telephonic and electronic portions of the CCM plan- do you have a CMA, or an RN to help?

How will they document the 20 minutes each month?

If you plan to use another clinician to provide call coverage, do they have access to the CCM plan and can they document if they end up providing non-face-to-face care?

Second…Any participating patients MUST have a written signed consent

Medicare does NOT have a universal consent form available, however, there are examples online that can be accessed that have been put into tool kits by FM organizations

http://www.aafp.org/fpm/2015/0100/fpm20150100p7-rt2.pdf

What does the Consent Consist of?

The Consent must explain the services and agreement of accepting the services provided

Must include authorization for electronic communication of his/her medical information with other treating providers as part of care coordination

Document in the patient record that services were explained and if the patient declined or accepted

The patient needs to be aware that they can stop CCM services at any time (effective at end of month)

Inform patient that only one provider can furnish and bill for services per month

Now What?

You now have your patient consented to CCM services, and your plan for who will be making the non-face-to-face contact with your patient, so what is required of you to bill for this on a monthly basis?

Plan of CareThe Plan should include, but is not limited to…

Problem List

Expected Outcome and Prognosis

Measurable Treatment Goals

Symptom Management

Planned Interventions

Medication Management

Community/Social Services Ordered

Individuals Responsible for Interventions

Scope of Services

8 Elements define the Scope:

1. 24/7 access- you must provide the patient with the means of access to care for any acute or urgent concerns in regards to their chronic care needs

2. Continuity of Care- you must provide the patient with the ability to follow up with the same designated clinician for routine care

3. Care Management for Chronic Conditions- this includes assessment of medical, functional, and psychosocial needs; making sure the patient is receiving preventative services at the correct times; med rec; and oversight of patients’ self management of meds

4. Create a Patient-Centered Care Plan- one that ensures the plan is congruent with patient choices and values

FPM has created a document in pdf form that can be used to help you (either use the document as is, or can be a template for you to create one)

http://www.aafp.org/fpm/2015/0100/fpm20150100p7-rt1.pdf

5. Manage health care transitions between and among health care providers and settings

Referrals

Follow Up visits after ER visit

Follow Up visits after hospitalization, skilled nursing facility, or other health care facility

Requires electronic exchange of clinical summary- it can’t be faxed

6. Coordinate with home and community-based clinical service providers

Ensures support of the patient’s psychosocial and functional needs

7. Enhanced opportunities for a patient and any relevant caregiver to communicate with the provider regarding the beneficiary’s care

this includes other non-face-to-face communication outside of using the telephone: secure messaging, internet, etc

8. Electronic Capture and Sharing of Care Plan Information

Any provider whose care time will count towards the 20 min of non-face-to-face care will need 24/7 access to the care plan

It must also be shared with any other providers, as appropriate, who are furnishing care for the beneficiary (fax not acceptable)

Important Notes to Remember

If you don’t meet 20 minutes of documented care coordination/planning, you can’t bill CCM services that month

The minutes do NOT ‘rollover’ once the month ends

Reimbursement is approx 42$ per patient for CCM code

Important Notes Cont…Be aware and be sure your patient knows that co-pays and deductibles DO apply to CCM services

Any minutes spent on CCM services that result in an office visit due to that phone call or secure messaging are no longer counted as CCM services- they are now considered to be part of the office visit

CCM Services do not include clinician time spent on refilling meds, completing Prior Authorizations, etc

Important Notes, cont…

CCM Services cannot be billed for in the same month if you bill Transition of Care Services (99495-99496)

CCM Services cannot be billed for in the same month if you bill Home Health Care Supervision/Hospice Care Supervision (G0181/G0182)

CCM Services cannot be billed for in the same month if you bill for certain ESRD services (90951-90970)

Referenceshttp://www.aafp.org/fpm/2015/0100/p7.html

https://www.acponline.org/system/files/documents/running_practice/payment_coding/medicare/chronic_care_management_toolkit.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf