Transcript Slide 1

Introduction to the Chronic Care
Management Code
March 12, 2015
Paul M. Rudolf, MD,
(202) 942-6426
[email protected]
Nicole Liffrig Molife
(202) 942-6611
[email protected]
Background
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Previously, non-face-to-face care management was bundled into
Evaluation/Management (E/M) services.
Payment for E/M services did not adequately account for the amount of work
to provide complex, coordinated care management for beneficiaries with
multiple chronic conditions.
New Current Procedure Terminology (CPT) Code 99490
– National Payment Rate for Chronic Care Management (CCM) in the non-facility setting is
$41.92 per beneficiary per month.
– Medicare will also pay hospitals under the Hospital Outpatient Prospective Payment
System (APC 0631, $53.72)
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Physician paid at the facility rate
– Beneficiary is responsible for the 20% co-insurance.
– MA Plans must offer enrollees at least traditional FFS benefits which now include CCM,
and will presumably pay for CCM in the way it currently pays for other physician services.
– Commercial payors will likely follow pay for CCM code because payors often follow CMS’
payment policy.
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In addition, CPT created a code for Complex Chronic Care Management (CCCM),
99487.
– Today, CMS does not pay for CPT Code 99487.
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CCM Requirements
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Eligible patients
Eligible professionals
Patient consent
Care coordination services
Specified practice capabilities
Specified use of EHR
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CCM Requirements
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Eligible patients
Eligible professionals
Patient consent
Care Coordination Services
Specified practice capabilities
Specified use of EHR
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Eligible Patients
 Patients must:
– Have two or more chronic conditions that are expected to
last at least 12 months (or until death), that
– Place them at significant risk of death, acute
exacerbation/decompensation, or functional decline.
 CMS has declined to publish a definition of qualifying
“chronic conditions” and is allowing practices to make
their own determinations about beneficiary eligibility.
 Although most observers believe the Centers for
Medicare & Medicaid Services (CMS) expect many
patients to qualify and for CCM to be billed frequently,
practices must keep in mind that the services must be
medically necessary.
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CCM Requirements
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Eligible Patients
Eligible professionals
Patient consent
Care Coordination Services
Specified practice capabilities
Specified use of EHR
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Eligible Professionals
 Who may bill for CCM services?
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Physicians (any specialty)
Advanced practice registered nurses
Physician assistants
Clinical nurse specialists
Certified nurse midwives
 Only one provider may bill CCM per patient per
month.
 If more than one provider bills, the first claim
submitted will be paid.
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Eligible Professionals (Cont.)
 Who may provide CCM services?
– CCM services may be provided by clinical staff, incident
to the services of a physician or mid-level practitioner,
under the general supervision of that physician or
practitioner.
– The supervising physician’s time may also count, but
the physician must be performing specified CCM
activities (time spent supervising does not count).
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Eligible Professionals (Cont.)
 Clinical staff include:
– Licensed professionals: nurses, technicians, therapists
– Non-physician practitioners:
physician assistants,
practitioners
nurse
 CCM services must “be provided by clinical staff,
specifically, rather than by other “auxiliary personnel” as is
the case for other “incident to” rules.
– Beyond suggesting that the definition of “clinical staff” is more
narrow than “auxiliary personnel,” CMS does not elaborate on what
credentials clinical staff must have to provide CCM services.
– Nevertheless, staff must be qualified to provide CCM support (e.g.,
administrative staff do not qualify).
– Further clarity is needed to determine whether clinical staff with a
defined scope of service but who may not be licensed or have
“official” credentials (e.g., medical assistants) are eligible to provide
CCM services.
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General Supervision
 General supervision:
– Physician is not required to be present in the office at the
time the service is furnished.
– CMS has not defined what activities count towards satisfying
the “general supervision” requirement for CCM services, but
may include:
• Team meetings/calls with clinical staff providing CCM services.
 Ultimately, supervising physician must provide
sufficient oversight to demonstrate ongoing
participation in the patient’s care and that CCM is
being delivered as part of the prescribed course of
treatment.
– Physician should document supervision activities
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Employment Arrangements
 Clinical staff need not be direct employees of the
practitioner or the practice.
– May be independent contractors.
• Our understanding is that clinical staff are not required to be
W-2 employees.
– There must be a “close relationship” between the
practitioner and clinical staff providing the services.
– Scope of services that may be provided under
arrangement has not been defined.
– Physician supervision is required and may be more
difficult to support if staff is not on-site.
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CCM Requirements


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Eligible patients
Eligible professionals
Patient consent
Care coordination services
Specified practice capabilities
Specified use of EHR
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Patient Consent
 Practices must obtain written consent from the beneficiary
to bill the CCM code.
– Consent must be documented in the electronic health record.
 Practice must:
– Inform the beneficiary of the availability of CCM services;
– Explain the type of services included in the CCM benefit;
– Inform the beneficiary of the right to stop the CCM services at any
time;
– Notify the beneficiary that only one practitioner can furnish and be
paid for these services during a calendar month; and
– Inform the beneficiary that they will be responsible for any
associated copayment or deductible.
 Beneficiary can terminate consent at any time.
 Retroactive consent not allowed
 Discussion point: refusal of beneficiary to consent.
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CCM Requirements
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Eligible patients
Eligible professionals
Patient consent
Care coordination services
Specified practice capabilities
Specified use of EHR
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Care Coordination Services
 Minimum of 20 minutes of non-face-to-face care
coordination services, such as:
 A provider may not count time spent by multiple clinical
staff during a single meeting more than once.
– If three staff members meet for 10 minutes to discuss a
beneficiary’s chronic care management, only 10 minutes may be
counted toward the billing code.
 There are also a number of services for which a provider
may not bill during a calendar month when CCM is billed,
e.g., transitional care management (CPT 99495 and
99496).
– Conversely, CCM cannot be billed for a calendar month during
which TCM is billed (e. g., if TCM is billed for the period Jan. 5 to Feb
4, CCM cannot be billed for Jan. or Feb.)
– Additionally, CPT Code 99490 may not be reported during a month
when the monthly ESRD capitation is billed or by a provider during
the postoperative period of a reported surgery.
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Care Coordination Services (Cont.)
 CMS has identified a non-exhaustive list of services that can be counted
towards the 20 minutes/per month requirement, including:
Development/revision of care plan
Coordination with other treating HCPs
Monitoring a patient’s physical, mental and social needs
Ensuring timely receipt of preventive care services
Performing medication reconciliation
Supervising patient self-management of medications
Managing care transitions, including follow-up after emergency department
visits and discharges from facilities
– Coordinating home and community based clinical service providers required to
support the patient’s mental and social needs
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 Additional care coordination/management services can be found at: 79
Fed. Reg. 67720-21.
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Documentation of Clinical Staff Activities
 CMS has provided little guidance regarding the level of
documentation required to bill the code.
 Billing providers should require clinical staff to
document their time and describe the CCM service
that was performed (i.e., coordinating care,
communicating with the patient, etc.)
 One Medicare contractor suggested that care team
members can record time increments as either “5
min.” or “10:05am – 10:10am.”
 The AAFP has posted several CCM tools, including a
sample time entry log, available at
http://www.aafp.org/fpm/2015/0100/p7.html.
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CCM Requirements






Eligible patients
Eligible professionals
Patient consent
Care coordination services
Specified practice capabilities
Specified use of EHR
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Practice Capabilities
 To bill the new CCM code, practices must provide:
– 24/7 patient access to address patients’ acute chronic care
needs;
– Continuity of care through a designated member of the care
team;
– Care management including systematic assessment of
patient’s medical, functional, and psychosocial needs;
– Creation of a comprehensive patient-centered care plan
document (which must be provided to the patient);
– Management of care transitions within the health care
system; and
– Enhanced
opportunities
for
provider-patient
communications. The care plan must be provided to the
patient, but need not be provided electronically.
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Practice Capabilities (Cont.)
 Practices should be careful to distinguish between:
– (A) The capabilities CMS requires a provider to have to
bill for CCM (e.g., use of a certified EHR for specified
purposes, coordinate care, maintain an electronic care
plan, etc.); and
– (B) When services count towards the 20 minute
minimum (e.g., clinical staff time can only be counted if
the clinical staff person meets the requirements for
electronic access to the care plan)
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CCM Requirements






Eligible patients
Eligible professionals
Patient consent
Care coordination services
Specified practice capabilities
Specified use of EHR
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The Care Plan
 Providers must electronically capture care plan
information in a certified electronic health record
(EHR) or other HIPAA-compliant health information
exchange platform.
 All care team members furnishing CCM services that
are billed by a given practice must have 24/7 access to
the electronic care plan information in order to count
their time toward the 20 minutes.
– Practice also must share care plan information, as
appropriate, with other providers outside of the practice,
using any electronic means (other than fax).
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The Care Plan: Providing Access
 The language of the final rule appears to provide
some discretion to practices in the manner in
which contracted clinical staff can access the
patient’s care plan and the amount of information
they are required to have.
– Remote access to the EHR.
– Web access to a care plan application.
– Web-based access to a health information exchange
service that captures care plan information.
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The Care Plan: Providing Access (Cont.)
 One Medicare Contractor has suggested that, in the
highly unlikely event that a billing practice that is
coordinating care or referring a patient to a non-CCM
billing practitioner who has no internet access, email
capability or ability to receive the care plan
electronically, then time spent coordinating with that
cannot be billed.
 We disagree, given the preamble explicitly states:
– the electronic care plan “would not have to be available at all
times to other non-billing practices, recognizing that other
practices may not be using compatible electronic technology
or participating in a health information exchange.” 79 Fed.
Reg. 67725.
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Use of EHR
 Certified EHR technology is only required for specified services,
including:
– Practice must create a structured recording of demographics,
problems, medications and medication allergies.
• This information must inform the care plan (although the care plan itself does
not need to be created or transmitted using a certified EHR), care coordination,
and ongoing clinical care.
– Practice must create a structured clinical summary record that is
formatted according to, at a minimum, the standard for the EHR
Incentive Program requirements from the previous calendar year.
– Practice must document in the patient’s medical record using the
certified EHR:
• Patient’s written consent an authorization for CCM services.
• Practice must also document that all of the CCM services were explained and
offered, and note the patient’s decision to accept or decline these services
– That a written or electronic copy of the care plan was provided to the
patient.
– Communication to and from home and community based providers
regarding the patient’s psychosocial needs and function deficits.
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Confusion Regarding the Use of EHR
 One Medicare Contractor has suggested that all practitioners
and clinical staff whose time is counted towards the 20 min.
requirement must have 24/7 access to the patient’s EHR.
 We disagree with this interpretation of the rule, and believe that
the 24/7 requirement only applies to accessing the electronic
care plan (which does not require transmittal via EHR).
 The Final Rule states that “the CCM service must be furnished
using [CCM certified EHR technology] to meet the final coretechnology capabilities . . . [and] to fulfill the CCM scope of
services requirements whenever the requirement references a
health or medical record.” (79 F.R. 67724)
 Nowhere in the rule does it state that care team members
counting time towards the 20 min. requirement must have 24/7
access to the EHR.
 However, there is no clear guidance on this issue and it remains
a grey area.
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Use of EHR: Privacy Concerns
 Providing access to off-site clinical staff may raise
privacy concerns, albeit not new ones.
 CCM rule requires physicians to document patient
authorization for electronic communication of his
or her medical information to be shared with
other treating providers in the EHR.
– Clinical staff team members (or their employers) who
are not part of the practice should sign business
associate agreements.
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Potential Business
Opportunities
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Potential Business Opportunities
 Opportunities for billing providers/practices
 Opportunities for vendors
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Opportunities for Billing Providers/Practices
 New revenue source.
 Ability to develop infrastructure to become a medical
homes or to participate in ACOs.
 Differentiate practice / provider for payors.
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Opportunities for Vendors
 Vendors can assist providers by:
– Developing systems and platforms to assist in
administrative tasks
– Providing remote technology platforms to
facilitate practices meeting the 24/7 access and
provider-patient communications scope of
service
 Opportunities also exist to provide clinical
staff on a contract basis to billing providers.
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Legal Risks
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Legal Risks: The Anti-Kickback Statute and
Stark Law
 Because physicians may be in a position to refer
business to vendors supplying CCM-related
services, arrangements between physicians and
vendors should comply with the federal AntiKickback statute.
 Arrangements between physicians and vendors for
the provision of CCM-related services could
implicate the Stark Law if there is the potential for
referrals for DHS between the two parties.
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Other Legal Risks
 Companies seeking to innovate in the area of enhanced
provider-patient communications should consider:
– FDA requirements
– Medical data privacy and security laws (e.g. HIPAA),
– Product liability risks (e.g., should the product fail to deliver
essential communications)
– Other tort or contractual claims
 Companies providing clinical staff should consider:
– State licensure laws
– State “fee-splitting” prohibitions (that proscribe certain healthcare
professionals from splitting professional fees with providers),
– Corporate practice of medicine prohibitions (that bar corporations
or other lay entities from practicing medicine and or interfering
with a doctor’s independent clinical judgment).
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Open Issues
•CMS has declined to provide guidance with respect
to use of CPT 99490
• We have already become aware that Medicare
Administrative Contractors and certain
consultants appear to have given advice that is not
consistent with advice given by specialty societies
• Physicians may want to consult experienced health
care legal counsel
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Discussion/Questions
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Acknowledgement
•We would like to thank the following Arnold &
Porter associates for their assistance in preparing
the presentation: Lauren Haertlein, Elizabeth Owens,
Nora Schneider, and Victoria Wallace.
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Thank you
Paul M. Rudolf, MD
Nicole Liffrig Molife
(202) 942-6426
[email protected]
(202) 942-6611
[email protected]