By DeARCY VAUGHAN, PHARMD
In 2010 Medicare saw that 46 percent of their total spending was going to patients with chronic conditions.
The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals.
In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions.
CPT code 99490 requires 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
- Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline
- Comprehensive care plan established, implemented, revised or monitored
There are multiple other CPT codes including complex CCM services that share a common set of service elements. They differ in the amount of clinical staff service time provided; the involvement and work of the billing practitioner; and the extent of care planning performed.
This means Medicare will reimburse the physician with 20 minutes of NON Face to Face time with the patient. But a complicated process discouraged the physician from providing the service leading to only 1.5 percent of 40 million eligible patients enrolled into the program.
Patient Eligibility includes the 3 items listed above. Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications or repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language. Examples of chronic conditions include, but are not limited to, the following:
- Alzheimer's disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Atrial Fibrillation
- Autism Spectrum disorders
- Cardiovascular Disease
- Chronic Obstructive Pulmonary Disease
- Infectious diseases such as HIV/AIDS
For a new patient or patient not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner - an Annual Wellness Visit (AWV) or Initial Preventive Physical Exam (IPPE), or other face-to-face visit with the billing practitioner. This initiating visit is not part of the CCM service and is separately billed.
Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]). G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.
Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical record.
The CCM service is extensive, including structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other case management services, and coordinating and sharing patient health information timely within and outside the practice.
- Structured Recording of Patient Health Information: Record the patient's demographics, problems, medications and medication allergies using certified Electronic Health Record (EHR) technology.
- Comprehensive Care Plan: A person-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental assessment, and an inventory or resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed)
A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:
- Problem list
- Expected outcomes and prognosis
- Measurable treatment goals
- Symptom management
- Planned interventions and identification of the individuals responsible for each intervention
- Medication management
- Community/social services ordered
- A description of how services of agencies and specialists outside the practice will be directed/coordinated
- Schedule for periodic review and, when applicable, revision of the care plan
This is where companies can provide services to help assist the physician. CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an "incident to" basis. These companies hire HIPAA certified, medical clinicians or case managers make the calls for the physician, record interactions with patients and Medicare reimburses the practice for every monitored patient. This means that a physician with 1,000 Medicare patients enrolled can generate around $20,000 of additional revenue each month.
If you would like to learn more about a company that can help implement CCM into your practice please contact: DeArcy Vaughan, PharmD, MBA, BCACP, CDE, CTTS with RX2Live at growrevenue.rx2live.co or firstname.lastname@example.org.