New Payment for Chronic Care Management Services

January 3, 2014

The 2014 Medicare Physician Fee Schedule notes preliminary guidelines for receiving separate payment for chronic care management services, beginning in 2015.

The 2014 Medicare Physician Fee Schedule (MPFS) final rule notes preliminary guidelines for receiving separate payment for chronic care management (CCM) services given to Medicare patients, beginning in 2015.

Under the 2015 MPFS, CMS will separately pay for CCM services provided to Medicare patients with multiple chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

The scope of CCM services is described in the 2014 MPFS final rule. Here is a summary:

• Patients and caregivers must receive 24/7 access to healthcare providers (to address a patient’s acute chronic care needs), and those healthcare providers must have 24/7 access to medical records.
• Patients must be able to get successive routine appointments with a specific practitioner or member of the continuity of care team.
• Practitioners must offer care management planning for patients with chronic conditions.
• Practitioners must facilitate management of care transitions - communication of relevant patient information through electronic exchange of a summary care record with other providers.
• The practice must coordinate with home and community-based clinical service providers required to support a patient’s psychosocial needs and functional deficits.
• Patients must be offered enhanced provider communication possibilities - not only via the phone, but also through secure messaging, Internet, or other non-face-to-face consultation methods.

These opportunities must be offered by the provider, but there is no mandate that the patient take advantage of them. Practices should provide patients with an Advanced Beneficiary Notice (ABN), before furnishing services, explaining what CCM services are, how they are accessed, how the patient’s information will be shared, and that cost-sharing applies to these services even when they are not delivered face-to-face.

CCM services standards established in the 2014 MPFS final rule will be implemented in 2015 through notice and other rulemaking.

Potential standards for practices include:

• Using a certified EHR that meets HHS regulatory standards for meaningful use.
• Employing at least one advanced practice registered nurse or physician assistant with written job roles including, and being appropriately scaled for, meeting the needs of patients receiving CCM services.
• Possessing written protocols regarding the furnishing of CCM services.
• Providing practitioners involved in furnishing CCM services (including advanced practice registered nurses or physician assistants) with access to the patient’s EHR at the time of service.

In billing for services, the qualified healthcare professional will be required to document in the patient’s medical record that all of the CCM services were explained and offered to the patient, specifically noting the patient’s decision to accept these services. Also, a copy of the care plan must be provided to the beneficiary - and this must be recorded in the EHR as well.

CMS is creating a new, separately payable G-code for 2015 that corresponds to 20 minutes of service during a 30-day period. This code creation recognizes how additional resources are needed to provide CCM services to patients with multiple chronic conditions.

Incident-to requirements apply to CCM services, including the exception to the rule, which allows general supervision of incident-to services given to homebound patients in medically underserved regions. CMS notes that the clinical staff furnishing the CCM services could be employed by either the physician or the practice.

Time spent by a clinical staff employee who is providing CCM services outside of the practice’s normal business hours can be counted towards the time requirement, if the following circumstances are met:

• The clinical staff person is directly employed by the physician or practice.
• The services of the clinical staff person are an integral part of the physician’s CCM services.
• The services provided are performed under the general supervision of the physician.

Renee Dustman is an executive editor for AAPC’s Healthcare Business Monthly magazine.