Wednesday Dec 24, 2014
Chronic care management: lots of questions and a few answers
Since the Centers for Medicare & Medicaid Services (CMS) published its final rule on the 2015 Medicare physician fee schedule – and especially since Family Practice Management (FPM) published its article “Chronic Care Management and Other New CPT Codes” – I have been inundated with questions. I will try to answer at least some of them:
Q1. Does doing prior authorizations for medications and tests over the phone or ordering them electronically satisfy the Chronic Care Management (CCM) scope of service?
A1. The CCM scope of service includes “medication reconciliation with review of adherence and potential interactions” as well as “oversight of patient self-management of medications.” It is debatable whether time spent on the phone doing prior authorization for medications and tests or time sending in such prior authorization electronically would count for this purpose. At this point, it is probably safer not to count time spent on prior authorizations as CCM time, although CMS has not explicitly addressed the question.
Q2. If we don't do 20 minutes of CCM in a month, but our work over two or three months adds up to 20 minutes, can we bill at that time for a month?
A2. No. Code 99490 is for 20 minutes “per calendar month.” You cannot add time up over multiple months to report 99490.
Q3. Can the case manager of a Medicare Shared Savings Program accountable care organization (MSSP ACO) who works under the physician's direction be counted for doing work outside of the office? It appears so as long as we record it.
A3. If the MSSP ACO case manager is a clinical staff person and the work that he or she does otherwise meets Medicare’s “incident to” rules relative to the physician who will be reporting 99490 (understanding that, for CCM, CMS allows “incident to” services to be provided under general, rather than direct, supervision), then his or her time may be counted toward the 20 minutes necessary to report code 99490, where appropriate.
Q4. When billing 99490, do we use the diagnosis codes for the two chronic care conditions we are using? I would think so but haven't found guidance so far.
A4. CMS has not specified what diagnosis codes should be reported with code 99490. Absent guidance to the contrary, it seems reasonable to report at least the two primary chronic care conditions for which you are providing 99490.
Q5. Can CCM services related to medication management be delivered by a clinical pharmacist embedded in the clinic? If yes, I assume the billing for the CCM services would still be under the supervising physician or mid-level provider, or can the clinical pharmacist bill directly for the CCM service?
A5. CMS has acknowledged that the services of pharmacists may be billed “incident to” those of a physician or other qualified health care professional, such as a nurse practitioner or physician assistant, as long as all of the “incident to” requirements are otherwise met. Thus, a clinical pharmacist could be counted among the clinical staff able to provide CCM services “incident to” the services of the physician or mid-level provider under whose provider number the services will otherwise be billed to Medicare. I do not believe that Medicare recognizes clinical pharmacists as providers for purposes of billing Medicare directly under Medicare Part B or the physician fee schedule.
Q6. How many work relative value units (RVUs) are assigned to the CCM code?
A6. The 2015 Medicare physician fee schedule assigns 0.61 work RVUs to code 99490.
Q7. Can only the physician create the care plan, or can the physician delegate it to other clinical staff? Also, can a mid-level provider, such as a nurse practitioner or physician assistant, acknowledge/sign the care plan?
A7. In the final rule on the 2015 Medicare physician fee schedule, in its discussion of the scope of the CCM service, CMS states, "In consultation with the patient, any caregiver, and other key practitioners treating the patient, the practitioner furnishing CCM services must create a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values." I interpret this to mean that the physician or non-physician practitioner who is nominally furnishing CCM services and, presumably, under whose provider number the services will be billed is responsible for creating the care plan. Also, CMS uses the word "practitioner" rather than "physician,” so I believe that a mid-level provider, such as a nurse practitioner or physician assistant, could acknowledge/sign the care plan if he or she created it.
Q8. I understand that I cannot bill CCM services for patients in a facility setting? How is “facility” defined?
A8. In the final rule on the 2014 Medicare physician fee schedule, CMS stated, "The resources required to provide care management services to patients residing in facility settings significantly overlaps with care management activities by facility staff that is included in the associated facility payment." CMS did not define "facility" beyond that. I interpret facility in this context to be any health care entity (e.g., hospital, skilled nursing facility, etc.) that receives a facility payment from Medicare.
Q9. I know CCM requires 20 minutes minimum. Is there an option to charge more if you spend a lot more time? I imagine many patients could take several hours per month.
A9. There is no current mechanism to charge Medicare more if you spend longer than 20 minutes. CPT has complex chronic care management codes that would facilitate that, and the AAFP encouraged CMS to use those codes for just this reason. However, for 2015, CMS is only recognizing and paying 99490, which is open-ended in terms of the time involved.
Q10. I know a patient-centered care plan is required. But must you complete it before doing any charges?
A10. The scope of service for CCM includes creation of a patient-centered care plan. CMS also requires that you provide a copy of that care plan to the patient. I believe CMS expects both of those things to be done before you report 99490 the first time.
Q11. Can you bill CCM for Medicare Advantage patients?
A11. You will need to check with the Medicare Advantage plans in your area regarding whether or not they will pay for 99490 in 2015. My understanding is that, in general, patients in Medicare Advantage plans are entitled to the same benefits enjoyed by patients covered under traditional Medicare. However, I have heard from some family physicians that some Medicare Advantage plans do not plan to cover and pay 99490.
Q12: Can you bill CCM for patients in an assisted living facility?
A12: CMS has stated in the final rule that physicians cannot bill CCM services for patients in a facility setting. CMS said, "The resources required to provide care management services to patients residing in facility settings significantly overlaps with care management activities by facility staff that is included in the associated facility payment." CMS did not define "facility" beyond that. I interpret "facility" in this context to be any health care entity (e.g., hospital, skilled nursing facility, etc.) that receives a facility payment from Medicare. If an assisted living facility is receiving Medicare facility payments for a given patient residing in that facility, I do not believe that you can report CCM for that patient.
Q13: Regarding 24/7 access to care management, is this defined as a phone call? Would 24/7 access for “urgent chronic care needs” by a patient portal be acceptable under the guidelines?
A13: Regarding 24/7 access to care management, CMS states, "To accomplish this, the patient must be provided with a means to make timely contact with health care providers in the practice to address the patient's urgent chronic care needs regardless of the time of day or day of the week." Elsewhere, CMS states that the scope of CCM services includes "Enhanced opportunities for the beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary's care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non face-to-face consultation methods." Based on this information, 24/7 access is not necessarily defined as a phone call.
Q14: If I am reading this right, we are not being asked to be available for “urgent acute care needs” but “urgent” issues regarding their chronic care conditions. Does Medicare define how quickly the provider must respond to the patient’s urgent care needs?
A14: As noted, CMS states, "To accomplish this, the patient must be provided with a means to make timely contact with health care providers in the practice to address the patient's urgent chronic care needs regardless of the time of day or day of the week." (Emphasis added) Thus, this access is related to "urgent chronic care needs." Medicare does not define "timely" in this context.
Q15: What do we use for a date of service?
A15: CMS has not addressed this particular question. Code 99490 is intended to encompass a calendar month's worth of work. Box 24 on the CMS-1500 claim form does permit a "from" and "to" date, so I would consider putting the first day of the month as the "from" date and the last day of the month as the "to" date for 99490 as a line item. (I presume electronic claims would also support this approach.) Because code 99490 does encompass the entire calendar month, I would refrain from billing it until the last day of the month, in much the same way that CMS expects providers to wait until the end of the 30-day period to report transitional care management (TCM) codes.
Q16: Can I bill CCM in the same month in which I see and treat a patient?
A16: I am not aware of anything that would prohibit you from reporting 99490 in the same calendar month during which you saw the patient and reported an appropriate evaluation and management code for that encounter. The only codes of which I am aware that CMS has stated you cannot bill in addition to CCM services for a patient during the same time period are TCM services (99495 or 99496), home health care supervision (G0181), hospice care supervision (G0182), or certain end-stage renal disease services (90951-90970).
For other questions and answers, check out the list of CCM frequently asked questions on the AAFP web site.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
Posted at 12:04PM Dec 24, 2014 by David Twiddy