Chronic Care Management FAQs

Note: This article provides information about the Centers for Medicare & Medicaid Services (CMS) Chronic Care Management services as gathered from this CMS Medicare Learning Network resource (published by CMS in December 2016 and accessed by Practice Fusion in October 2017).

This article provides information and frequently asked questions (FAQs) on the following topics that may be helpful to providers interested in billing Medicare Part B for Chronic Care Management (CCM) services:

  • Billing for CCM services
  • CCM eligibility
  • Patient eligibility and consent
  • CCM service elements

Billing for CCM services
CMS currently supports reimbursement for CCM services that fall under two categories: chronic care management (CCM) and complex care management services (complex CCM). Some components of the CCM service requirements for being reimbursed can be met using the Practice Fusion EHR, but other components require work that must be completed outside of the EHR. CCM services can be billed using the codes listed in Table 1.

Table 1. Billing codes for CCM Services in CY2017

CPT Code

Description

99490

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored

Assumes 15 minutes of work by the billing practitioner per month

99487

Complex chronic care management services, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Establishment or substantial revision of a comprehensive care plan
  • Moderate or high complexity medical decision making
  • 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

99489

Complex chronic care management services - each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately. Report 99489 in conjunction with 99487. Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month.

CCM Eligibility
Physicians and the following non-physician practitioners may bill CCM services:

  • Certified Nurse Midwives
  • Clinical Nurse Specialists
  • Nurse Practitioners
  • Physician Assistants

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 (as an integral part of services provided by the billing practitioner), subject to applicable State law, licensure, and scope of practice.

The clinical staff are either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM.

Time spent directly by the billing practitioner or clinical staff counts toward the threshold clinical staff time required to be spent during a given month in order to bill CCM services. Non-clinical staff time cannot be counted toward the threshold. The CCM codes (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare Physician Fee Schedule, which means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required.

Patient Eligibility & Consent
CCM services can be reimbursed when delivered to patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

CMS requires that providers who bill for CCM services get consent from the patient prior to submitting for reimbursement because this ensures the patient is engaged and aware of applicable cost sharing that is required for the services. It may also help prevent duplicative practitioner billing. Consent may be verbal or written but must be documented in the medical record, and includes informing them about:

  • The availability of CCM services and applicable cost-sharing
  • That only one practitioner can furnish and be paid for CCM services during a calendar month
  • The right to stop CCM services at any time (effective at the end of the calendar month)

CCM Service Elements
CCM and complex CCM services share a common set of service elements, but 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. These service requirements are extensive, and include structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the practice.

Table 2 below provides a summary of the service requirements for billing CCM and complex CCM services. Some components of the CCM service requirements can be met using the Practice Fusion EHR, but other components require work that must be completed outside of the EHR. Note that although the Practice Fusion EHR has several functional components that support CCM service elements, providers must utilize those features appropriately to meet CCM billing requirements.

Table 2. CCM Service Summary

CCM Service Requirement Summary

Supported by the Practice Fusion EHR?

Structured Recording of Patient Health Information

Structured Recording of Patient Health Information
Record the patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology certified to the 2014 Edition or 2015 Edition.

Yes

Comprehensive Care Plan

Creation, revision, and/or monitoring (as per code descriptors) of an electronic person-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues with particular focus on the chronic conditions being managed.

Yes

Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the patient’s care.

Yes

A copy of the plan of care must be given to the patient and/or caregiver. This can be done either electronically or via other methods.

Yes

Access to Care & Care Continuity

Provide 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified health care professionals or clinical staff, including providing patients (and caregivers as appropriate) with a means to make contact with healthcare professionals in the practice to address urgent needs regardless of the time of day or day of week

Not supported. This requires services and actions outside the EHR

Ensure continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments

Not supported. This requires services and actions outside the EHR

Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care by telephone and also through secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods (for example, email or secure electronic patient portal)

Partially supported. Secure internet messaging is available using the Practice Fusion EHR and patient portal

Comprehensive Care Management

Systematic assessment of the patient’s medical, functional, and psychosocial needs

Not supported. This requires services and actions outside the EHR

System-based approaches to ensure timely receipt of all recommended preventive care services

Partially supported. EHR clinical decision support alerts can help with select preventive care services but also requires additional actions outside the EHR.

Medication reconciliation with review of adherence and potential interactions

Not supported. This requires services and actions outside the EHR but can be documented in Practice Fusion.

Oversight of patient self-management of medications

Not supported. This requires services and actions outside the EHR

Coordinating care with home and community based clinical service providers

Not supported. This requires services and actions outside the EHR

Medical Decision Making

Complex CCM services require and include medical decision-making of moderate to high complexity (by the physician or other billing practitioner).

Not supported. This requires services and actions outside the EHR

FAQs

1. What conditions are considered chronic in terms of determining beneficiary eligible for chronic care management and complex chronic care management services?A patient must have two or more chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Such conditions are, but not limited to: Alzheimer’s disease and related dementia, asthma, cancer, depression, diabetes, ischemic heart disease, and osteoporosis.

2. What are the technology requirements for practices billing for chronic care management services?
There are two types of technology requirements included under the Chronic Care Management program from CMS, EHR technology requirements and electronic care plan requirements.

EHR Technology Requirements

  • Must be using certified EHR technology that meets either the 2014 Edition or 2015 Edition certification criteria required under the EHR Incentive Program for the calendar year
  • Physician must record the following information as structured data in the certified EHR technology: demographics, problems, medications, and medication allergies
  • Allow for the creation of a structured clinical summary record (consistent with 45 CFR 170.314(e)(2))
  • Provider must be able to transmit the summary record for purposes of care coordination
  • House the beneficiary consent of CCM services
  • House the beneficiary receipt of care plan (electronic/hard copy)
  • Document communication to and from home and community-based providers

Electronic Care Plan Requirements

  • Allow provider to create an electronic care plan based on the physical, mental, psychosocial, cognitive, functional and environmental assessment of beneficiary
  • Ability to update and share care plan with other practitioners and care members on a 24/7 basis
  • Opportunities for beneficiary and any caregiver to communicate with the practitioner

3. Is patient consent required before a practice can furnish or bill for CCM services?
Yes. A practice must obtain a written agreement to have CCM services provided, including authorization for electronic communication of medical information with other treating physicians or providers. An explanation of the CCM services and whether the patient gave consent should be noted in the patient’s medical record. The patient should also be informed:

  • Of the right to discontinue CCM and the effect of revoking the agreement
  • One practitioner can furnish and be paid by Medicare for CCM within the service period
  • Cost-sharing applies

4. Does the beneficiary consent require yearly renewal?
No, as provided in the CY 2014 PFS final rule (78 FR 74424), a new consent is only required if the patient changes billing practitioners, in which case a new consent must be obtained and documented by the new billing practitioner prior to furnishing the service.

5. Who qualifies as “clinical staff” for the Chronic Care Management program? If the billing physician (or other appropriate practitioner) furnishes services directly, does their time count towards the required minimum 20 minutes of time?
In most cases, clinical staff will provide CCM services incident to the services of the billing physician (or other appropriate practitioner who can be a physician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife). In addition, time spent by clinical staff may only be counted if Medicare’s “incident to” rules are met such as supervision, applicable State law, licensure and scope of practice. If the billing physician (or other appropriate billing practitioner) provides CCM services directly, that time counts towards the 20 minute minimum time. Of course, other staff may help facilitate CCM services, but only time spent by clinical staff may be counted towards the 20 minute minimum time.

6. Can CCM services be subcontracted out to a case management company?
A billing physician (or other appropriate practitioner) may arrange to have CCM services provided by clinical staff external to the practice (for example, in a case management company) if all of the “incident to” and other rules for billing CCM to the PFS are met. Because there is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9), CCM services cannot be billed if they are provided to patients or by individuals located outside of the United States.

7. Does the billing practice have to furnish every scope of service element in a given service period, even those that may not apply to an individual patient?
The expectation from CMS is that all of the scope of service elements will be routinely provided in a given service period, unless a particular service is not medically indicated or necessary (for example, the beneficiary has no hospital admissions that month so there is no management of a transition after hospital discharge).

8. What date of service should be used on the physician claim and when should the claim be submitted?
The service period for CCM is one calendar month, and CMS expects the billing practitioner to continue furnishing services during a given month as applicable after the 20 minute time threshold to bill the service is met. However practitioners may bill Medicare at the conclusion of the service period or after completion of at least 20 minutes of qualifying services for the service period. When the 20 minute threshold to bill is met, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month.

9. If an on-call physician who is not part of the group practice has access to the patient’s medical records, does that meet the definition of 24/7 access?
If the physician has a contractual arrangement and it falls within the incident-to rules, then that would be acceptable for 24/7 access.

10. Can I bill for chronic care management services if the beneficiary dies during the service period?
Chronic care management services can be billed if the beneficiary dies during the service period, as long as at least 20 minutes of qualifying services were furnished during that calendar month and all other billing requirements are met.

11. Is charting time completed by a nurse within the physician’s practice counted toward chronic care management clinical staff time?
Yes. Chart documentation related to the CCM services is counted as part of required the 20 minutes of clinical staff time.

12. Do only face-to-face activities count as billable time under chronic care management?
CCM services include activities that are not typically or ordinarily furnished face-to-face, such as telephone communication, review of medical records and test results, and consultation and exchange of health information with other providers. If these activities are occasionally provided by clinical staff face-to-face with the patient but would ordinarily be furnished non-face-to-face, the time may be counted towards the 20 minute minimum to bill CCM services

13. Are there patient cost-sharing requirements for chronic care management services?
Yes, 20% coinsurance is required (which results in approximately an $8.00-$8.50 monthly co-pay), but if the member has supplemental insurance or is a dual-eligible (Medicare and Medicaid), the copayment will likely be covered.

Quality Payment Program

  1. 2018 Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  2. What is the MIPS Dashboard watch list and how do I use it?
  3. How does the MIPS Dashboard work?
  4. What is the Promoting Interoperability (formerly Advancing Care Information) performance category in MIPS?
  5. 2018 What is the Quality performance category in MIPS?
  6. 2018 What are Improvement Activities in MIPS?
  7. Which Improvement Activities qualify for the Promoting Interoperability performance category bonus in 2018?
  8. What is the Cost performance category of MIPS and how is it scored in 2018?
  9. How is the MIPS Final Score Calculated in 2018?
  10. What is a MIPS eligible clinician in 2018?
  11. MIPS for Small, Rural and Underserved Practices
  12. 2018 PI Transition Measure: Medication Reconciliation
  13. 2018 PI Transition Measure: Electronic Prescribing (eRx)
  14. 2018 PI Transition Measure: Secure Messaging
  15. 2018 PI Transition Measure: Security Risk Analysis
  16. 2018 PI Transition Measure: Health Information Exchange
  17. 2018 PI Transition Measure: Immunization Registry Reporting
  18. 2018 PI Transition Measure: Specialized Registry Reporting
  19. 2018 PI Transition Measure: Syndromic Surveillance Reporting
  20. 2018 PI Transitional Measure: View, Download, or Transmit (VDT)
  21. 2018 PI Transition Measure: Provide Patient Access
  22. 2018 PI Transition Measure: Patient-Specific Education
  23. What is the Practice Fusion QCDR?
  24. 2017 Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  25. How do I report my 2017 MIPS data to CMS using the Practice Fusion QCDR?
  26. What is the Advancing Care Information (ACI) Performance Category for MIPS and how is it scored?
  27. 2017 ACI Transition Measure: Security Risk Analysis
  28. 2017 ACI Transition Measure: Electronic Prescribing (eRx)
  29. 2017 ACI Transition Measure: Provide Patient Access
  30. 2017 ACI Transition Measure: Health Information Exchange
  31. 2017 ACI Transition Measure: View, Download, or Transmit (VDT)
  32. 2017 ACI Transition Measure: Patient-Specific Education
  33. 2017 ACI Transition Measure: Secure Messaging
  34. 2017 ACI Transition Measure: Medication Reconciliation
  35. 2017 ACI Transition Measure: Immunization Registry Reporting
  36. 2017 ACI Bonus Measure: Syndromic Surveillance Reporting
  37. 2017 ACI Bonus Measure: Specialized Registry Reporting
  38. What is the Improvement Activities Performance Category for MIPS?
  39. What are the Quality performance category reporting requirements for MIPS?
  40. What is the difference between the two Advancing Care Information measure sets available in 2017?
  41. What are Alternative Payment Models (APMs) and Advanced APMs?
  42. What is Comprehensive Primary Care Plus (CPC+)?
  43. Which Improvement Activities Qualify for the Advancing Care Information (ACI) Bonus Score in 2017?
  44. How do I contact CMS about the Quality Payment Program?
  45. How do I indicate interest in the Practice Fusion QCDR and get my MIPS estimated scores?
  46. Chronic Care Management FAQs
  47. How do I export a JSON file for 2017 MIPS reporting?
  48. How is the MIPS Final Score Calculated in 2017?

Feedback and Knowledge Base