Chronic Care Management

CMS Clarifies Use of CCM Code in Medicare Advantage Plans

April 14, 2015 03:07 pm News Staff
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CMS recently cleared up some confusion regarding physicians' use of the chronic care management (CCM) CPT code when billing for chronic care services provided to patients enrolled in Medicare Advantage plans.

Most family physicians know that on Jan. 1, traditional Medicare Part B began paying physicians for CCM services. But weeks later, CMS officials could not verify that Medicare Advantage plans were required to recognize the code.

That lapse in information led AAFP Board Chair Reid Blackwelder, of Kingsport, Tenn., to fire off a letter to CMS on March 5(3 page PDF) in which he asked CMS to "specify that all Medicare Advantage plans recognize and provide reimbursement for the CCM."

CCM Codes and Medicare Advantage at a Glance

In a recent call with the AAFP and other physician groups -- and a follow-up memo to Medicare Advantage organizations -- CMS addressed whether physicians could bill for chronic care management (CCM) services provided to Medicare Advantage plan members using the CCM code implemented on Jan. 1.

In summary:

  • Medicare Advantage plans already provide care coordination.
  • Physicians treating patients enrolled in such plans cannot bill for services using the CCM code unless the contract between the Medicare Advantage plan and the physician specifically provide for such coverage.
  • If a patient enrolled in a Medicare Advantage plan chooses an out-of-network physician to provide CCM services, then that physician can bill for those services using the CCM code.

Fee-for-service-plans, as well as PACE plans( -- also referred to as Programs of All-Inclusive Care for the Elderly -- are not coordinated care plans and therefore must cover all Medicare A and B services, including the CCM code.

Fast forward to April 10, when CMS provided more detailed information via a conference call with the AAFP and other national physician groups. Details of that call were made official in a memo distributed later that day to Medicare Advantage organizations.

In that correspondence, Kathryn Coleman, director of the Medicare Drug & Health Plan Contract Administration Group, confirmed that the CCM was a covered Medicare Part B service "included in the basic benefit offered by every MA (Medicare Advantage) plan."

However, Coleman noted that Medicare Advantage organizations "have wide latitude" in terms of furnishing care coordination services to beneficiaries.

"Medicare Advantage regulations … expressly preclude CMS from interfering in payment rates agreed to by an MA plan and its contracted providers," said Coleman. Whether such a plan pays physicians for furnishing care coordination via the CCM CPT code or some other mechanism "can vary depending on the contract agreement in place," she said.

Coleman provided additional information regarding patients enrolled in preferred provider organizations who "have the option to obtain covered services from non-contracted providers."

If a patient chooses an out-of-network provider to provide care coordination management services -- and the criteria for billing the CCM code is satisfied -- the Medicare Advantage plan must pay for the services as an out-of-network physician service.

Patients would be responsible for the out-of-network cost-sharing in this scenario, she added.

Coleman noted two important CCM requirements that physicians should keep in mind: The patient receiving the CCM services must authorize the physician to provide those services, and only one physician may bill for those services in a single month for a given patient.

The CMS press office said a copy of the memo was not available online for physician review.

Related AAFP News Coverage
Medicare Advantage Plan Update
AAFP Calls for CCM Coverage, Solid Networks, Standardized Directories