November 30, 2018, 04:35 pm Sheri Porter – If you are a family physician, odds are high that a portion of your patient panel is 65 or older and a Medicare beneficiary.
And of these patients, a good percentage probably live with two or more chronic diseases that are well managed by your family medicine clinic.
Unfortunately, too many family physicians who can nod in agreement with this scenario are not using chronic care management (CCM) codes to bill for these important patient services.
They should be.
In 2015, CMS implemented CPT code 99490, which enables physicians to bill and receive payment for CCM services to certain qualifying Medicare patients. CMS added CPT codes 99487 and 99489, as well as Healthcare Common Procedure Coding System code G0506, in 2017.
For the record, CMS defines CCM as non-face-to-face services provided to Medicare beneficiaries with two or more chronic conditions that are expected to last at least 12 months or until the patient dies. See the sidebar below for full descriptions of the current CCM codes. CMS will implement another CCM code -- 99491 -- in January 2019.
CCM services include
Samuel "Le" Church, M.D., M.P.H., of Hiawassee, Ga., describes himself as a self-taught expert on the use of CCM codes. This solo family physician has more than 4,000 patients who consider his clinic, Synergy Health Inc., to be their medical home.
And some 400 of those patients have agreed to participate in a CCM plan.
"I have more than I can do alone," Church told AAFP News. He relies on his clinical staff to take on some of the work involved in managing these patients.
He described his initial interest in the codes when they first became available.
"As a solo physician pursuing patient-centered medical home recognition from the National Committee for Quality Assurance, embracing the chronic care model was going to be resource-prohibitive," said Church.
The three CPT codes currently available to report CCM services are
Healthcare Common Procedure Coding System code G0506 compensates physicians for the extra time and effort it takes to initiate CCM with a patient. This code includes comprehensive assessment of and care planning for patients requiring CCM services. It is an add-on code and should be reported with another code for a patient encounter during which the physician initiates CCM with a patient.
Keep in mind that beginning Jan. 1, 2019, CPT code 99491 will be available to bill for 30 minutes of CCM services provided by a physician or other qualified health care professional.
"CCM payments came along at the perfect time, giving our team a mechanism to deliver reimbursable coordinated care management services. Without CCM payments, we would not have been able to fiscally support that level of personalized proactive service," he added.
In fact, said Church, "Not only have we hired additional staff to help manage our program and to closely coordinate achievement of quality metrics, we have been able to compensate all the members of our team at above-average rates, including the clinicians. This is a team effort."
Payment details outlined in a supplement published in the July/August 2017 issue of FPM highlight the increase in monthly income that is possible for practices that learn to leverage CCM codes. Based on national averages, practices can earn an additional
"There simply is no excuse for us to spend so much energy complaining about low reimbursement for care while this payment mechanism is available to help us to care for our sicker patients," said Church.
However, it's clear when this physician talks about managing the care of his patients with multiple chronic diseases that the increased revenue is just part of the equation.
"Perhaps more important is that our patients are less likely to be hospitalized or go to the emergency department when followed in a care management program. And closely connected to that, there are cost savings to the health care system as a whole."
Church noted that family physicians have long embraced the medical home model as the best way to provide comprehensive patient care. "That's just how we do business," he said.
But there are only so many tasks that can be squeezed into an office visit.
"With CCM, your team can address some needs or quality metrics outside of the precious and limited face-to-face time. If the model is fully embraced, the in-person time can emphasize the 'caring' aspect of family medicine and include activities that are most appropriately conducted in the clinic setting.
"So, while we have been doing some version of this model of care for many years, we just didn't get paid for it," said Church. "CCM is also a fiscal recognition of the value of our work."
Even as Church champions CCM services, he recognizes the pitfalls.
"It is an ongoing challenge that the CCM code set requires coinsurance. That is a barrier to some physicians who feel like it's difficult to ask folks to pay for things they were getting for free, and I appreciate that. But as I've had conversations with my patients, they are happy to know that we're paid for the care we're providing them."
Church explained that for patients with straight Medicare and a supplemental plan, there is no additional fee once their deductible is met. However, Medicare Advantage plans require a copayment of 20 percent for every billed service -- generally $7 to $10.
"While it is my hope that one day the CMS policy on coinsurance will change, it is perhaps a positive that we are challenged to show our patients the value of the services they are receiving," added Church.
Also, in Church's estimation, most electronic health record (EHR) systems hinder CCM work.
"Most of our EHRs are not designed to support this; their focus is to document patient encounters, not care management. There are, however, a few products out there that are beginning to facilitate this work and take some of the burden off the staff," said Church.
Church said that the initial learning curve of the CCM coding rules was, for him, pretty simple.
"A care plan is required, but doctors are trained on that; we do that every day with our patients," said Church. He added that the phrase "care plan" tends to give doctors pause.
"I think it's a lot less intimidating to refer to this as a comprehensive plan of care, and consolidating it into something a little more robust than a visit note -- but less verbose than our typical handouts -- requires a little practice," said Church.
Guide and leverage your team to assist with this task to create more efficiency, he suggested.
Shifting away from episodic care as the foundation of patient care is not a new concept, said Church. "CCM is just a CPT-based alternative to being part of an alternative payment model. It is crucial that physicians lead and embrace the comprehensive approach to patient care.
"Your team will follow," he added.
Church warned of growing pains if physicians enroll 100 patients right away and try to fully implement their program in the first month. Instead, he advised his colleagues to "start slowly, and use existing staff to deliver CCM services to known higher-need patients. Except for the formal care plan, your staff is likely already meeting the requirements," he said.
Where should physicians turn for additional guidance?
Church recommended that physicians rely on AAFP resources, including the AAFP CCM Toolkit, to gather all the information needed to get started. (Have your member ID ready when ordering the toolkit to get the member price of $69; nonmembers pay $139.)
FPM also offers a collection of articles related to coding.