Chronic Care Management. Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky

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1 Chronic Care Management Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky

2 Agenda Chronic Care Management (CCM) History Define Requirements 2016 Specifications for RHC/FQHC Revenue Benefits Quality Score Benefits Implementation Suggestions 2

3 Chronic Care Management We have already cut back on our schedule because of the time it takes to document It s another government regulation we need to document for Another item I need to document I don t have time... LET S TAKE A DEEPER LOOK! THIS IS MORE POSITIVE THAN WHAT YOU MAY THINK! 3

4 CCM Background Effective January 1, 2015, implementation of CCM for Medicare Fee for Service providers Effective January 1, 2016, CMS regulations allow for CCM service in RHC/FQHC Reimbursement under Medicare Physician Fee Schedule CPT Code

5 CCM Background Quality Patients managed under CCM will lead to improvement in quality scores and provide an overall reduction in healthcare spending. Quality Cost 5

6 CCM Requirements Patients with 2 or more chronic conditions: Lasting for the next 12 months, or Until death of the patient These conditions would place the patient at significant risk of death, exacerbation or functional decline. CMS maintains a Chronic Condition Warehouse (CCW) 6

7 CCM Consent Prior to providing CCM services we will need to obtain written consent. Consent includes: Nature of CCM How CCM is accessed One provider at a time to furnish CCM Health information will be shared with other providers for care Patient may stop CCM at any time by revoking Patient is responsible for co-insurance/deductible 7

8 CCM Providers Majority of CCM services are directed by: Primary Care Providers: MD, DO, NP, PA Specialists: only if providing the majority of services Clinical Staff can assist: RN LPN CMA Pharmacists Technicians Therapists 8

9 CCM Providers CMS has indicated that other staff may help facilitate CCM services but only time spent by clinical staff may be counted towards the 20 minute minimum time. 9

10 CCM Requirements 20 minutes of non face-to-face per encounter per month: Certified healthcare professional under general supervision of Primary Care Provider Incident-to exceptions to include that provider does not need to be in the same location as the professional providing coordination Exception: RHC/FQHC 10

11 CCM Requirements Direct Supervision in RHC/FQHC: Requires that a RHC/FQHC practitioner be present in the RHC/FQHC and immediately available to furnish assistance and direction. The RHC/FQHC practitioner does not need to be present in the room when the service is furnished. There is no exception to the direct supervision requirement at this time for CCM services furnished by auxiliary staff in RHCs/FQHCs. 11

12 CCM Requirements Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record: Using a certified EHR Not required to be a meaningful user of the technology but is required to utilize elements of the EHR technology = using CCM certified technology 45 CFR (a)(3)-(7) 12

13 CCM Requirements Clinical summary record: Provider s name and office contact information Date and location of visit Reason for visit Immunizations/medications administered during visit Diagnostic tests Clinical instructions Future appointments and scheduled tests Referrals to other providers Recommended patient decision aids 45 CFR (e)(2) 13

14 CCM Requirements The provider must be able to transmit the summary care record electronically for purposes of care coordination. CMS does not specify acceptable methods of transmission but does state that facsimile transmission is not acceptable. This is not to say that you can not transmit via fax, but that if you do not have a means to electronically transmit, you will not meet the requirements of CCM. 14

15 CCM Requirements Summary of Care Record Electronic Comprehensive Care Plan 15

16 CCM Requirements Comprehensive Plan of Care: Physical body Mental brain Cognitive understanding Psychosocial interactions Functional abilities Environmental surroundings 16

17 CCM Requirements Comprehensive Plan of Care (continued): A current list of providers that are involved in providing medical care An assessment of patient s preventive healthcare needs Plan should address all health issues (not just the chronic conditions) Applicable to patient s choices 17

18 CCM Requirements Comprehensive Plan of Care (continued): Problem List Medication Management Expected outcome and prognosis Measurable treatment goals Symptom management and planned interventions 18

19 CCM Requirements The preparation and updating of this care plan is not part of a reimbursable visit for CCM services. This will be billed separately as an evaluation and management service, annual wellness visit, or an initial preventive physical exam. The plan, once developed, will need to be updated annually. 19

20 CCM Requirements 24/7 access to care management services Patient to access a member of care team Remote access, web-based access Contact with a healthcare provider for urgent chronic care needs Regardless of time or day of week Access to a designated practitioner with whom the patient is able to get routine successive appointments Continuity of care with provider team 20

21 CCM Requirements Management of care transitions examples include: Referrals Emergency Department Inpatient Stay Skilled Nursing Facility Transitional Care Management (TCM) services and CCM cannot be billed during the same month. 21

22 CCM Requirements Coordination of home and community clinical based service providers to support psychosocial needs and functional deficits Document as CCM service: Home Health Hospice Outpatient therapy Durable Medical Equipment Transportation Services Nutrition Services 22

23 CCM Requirements Opportunity for patient and any relevant caregiver to communicate with provider: Phone Secure Messaging Internet Asynchronous non face-to-face method 23

24 Digging Into the Details of CCM 24

25 CCM Consent Document the beneficiary s written consent and authorization in the EHR using CCM certified technology. Inform beneficiaries in advance of their eligibility for CCM, documenting the explanation and offer. Document written informed consent (or decline), including permission to electronically share relevant medical information with other providers. Inform of the right to discontinue CCM, verbally or in writing, at any time (effective at the end of the service period) and the effect of revoking the agreement. Inform that only one practitioner can furnish and be paid by Medicare for CCM within a service period. Inform that cost sharing applies. Retroactive consent is not allowed. 25

26 CCM Documentation Details Some items we already address: Medication Reconciliation Medication Management (refills) Completion of forms (DME) Coordination of Care Referrals 26

27 CCM Documentation Details CMS does not specifically address the documentation requirements for CCM: Recommended: Date of service CCM provided Time (start and stop) Name of individual providing service and credentials Description of service provided 27 27

28 Prior to CCM Billing Make sure patient is seen by a provider prior to starting CCM billing. Obtain an informed written consent for CCM services; let them know 20% co-insurance applies. Explain to patient they can only be enrolled with one provider for CCM within the calendar period provide information on how they can revoke consent. 28

29 Prior to CCM Billing Document in patient s medical record that they opted to accept or decline CCM services. Ensure patient receives copy of consent and care plan; documented in medical record. Documentation of the 20 minute cumulative non face-to-face encounters. Phone calls s with patient Medication reconciliation, prescription management Time spent coordinating care and resources 29

30 Prior to CCM Billing Ensure that all elements for calendar month are met prior to billing CPT code Avoid duplicate billing for Transitional Care Management (TCM) or Telemedicine billing codes in the same month. 30

31 RHCs and FQHCs Beginning on January 1, 2016, RHCs/FQHCs may receive an additional payment for the costs of CCM services that are not already captured in the RHC all-inclusive rate or the FQHC prospective payment system (PPS) rate for CCM services to Medicare beneficiaries. 31

32 RHCs and FQHCs Can bill for CCM services when a practitioner furnishes a comprehensive evaluation and management (E/M) visit, Annual Wellness Visit (AWV), or an Initial Preventive Physical Examination (IPPE) to the patient prior to billing the CCM service and initiates the CCM service as part of the visit. 32

33 RHCs and FQHCs The Direct Supervision Requirement applies for the 20 minute non face-to-face. This is a new regulation for the RHCs/FQHCs Payment for this service is based on the Medicare PFS national average non-facility payment rate when CPT code is billed alone or with other payable services on a RHC or FQHC claim. 33

34 RHCs and FQHCs Coinsurance will be applied as applicable to FQHC claims. Coinsurance and deductibles would apply as applicable to RHC claims. The rate for CPT code will be updated annually and has no geographic adjustment rate is $ % coinsurance applies $38.28 Per CGS Kentucky 34

35 RHCs and FQHCs RHC and FQHC face-to-face requirements are waived when CCM services are furnished to a RHC/FQHC patient. Cannot bill for CCM services for a beneficiary during the same service period as billing for transitional care management (TCM) or any other program that provides additional payment for care management services (outside the RHC/FQHC payment) for the same patient. 35

36 RHCs and FQHCs Billing for CCM services: UB-04 Revenue Code 52X CPT code Date of service is the date that 20 minutes of non face-to-face has been met or any date after that prior to the end of the month. 36

37 Return on Investment Scenario: Reimbursement is $38 per patient, per month 150 Medicare FFS patients qualify for CCM $456 per patient, per year x 150 CCM patients $68,400 Total Revenue 1.0 FTE for Care Coordinator $40 - $50,000/year ROI = $18,400 - $28,400/year 37

38 CCM Outcomes CCM billing income to cover Care Coordinator Effective care coordination to improve patient outcomes and reduce cost Needed to participate in value based payment models in the future 38

39 Getting Started 39

40 CCM Process - Stage 1 Who are your eligible patients? Use your EHR to search for patients that have 2 or more chronic conditions. Run internal reports sorted by provider. Make sure you cross-check for duplicates. The patient must have 2 or more chronic conditions that have the following required elements: Chronic conditions that are expected to last at least 12 months or until death; and Place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. 40

41 CCM Process - Stage 1 Recommended to start small with a specific chronic condition such as diabetes, COPD, hyperlipidemia. Create a log of participating CCM patients, referred to as a registry. 41

42 CCM Process - Stage 2 Select staff based on need for each identified patient primary clinician, nurse, and other staff helping with consents and scheduling. Patients per hour 3 Patients per day 24 Patients per week 120 Patients per month 480 Patient should be able to access successive routine appointments with the designated clinician. 42

43 CCM Process - Stage 2 Other clinical staff can provide services incident to the primary clinician, as long as the primary provider is providing general supervision (physician practice). Direct supervision (RHC/FQHC) 43

44 CCM Process - Stage 3 Build a CCM process Set up appointment codes for new CCM visits and nurse assessment calls as needed Templates for documentation References supporting CCM discussions Protocols for disease management discussions; standing orders As enrollment increases, consider designating time schedule for clinician visits and nurse calls. 44

45 CCM Process - Stage 3 Educate all staff regarding CCM nurse(s) and staff to assist with enrollment, consents, scheduling, and other related CCM activities. Consider a dedicated phone line that would be answered by designated CCM staff and forwarded to on-call clinician after hours, if needed. 45

46 CCM Process - Stage 4 Inform the Patient Educate patients to participate Phone education in the beginning Brochures; pamphlets Letter Explain how it works and that they can decline, transfer, or terminate at any time. Provide information on how to terminate or transfer 46

47 CCM Process - Stage 4 Inform patients regarding authorization of electronic communication of medical information with other clinicians. Provide designated provider s name as well as the CCM nurse. Explain the monthly scheduled nurse discussion, which should be treated like a regular visit even though it will occur by phone, or discussions with other clinical staff can be considered part of the service Explain how and when the bills will be submitted and what the patient s obligations are for payment of coinsurance and deductibles. 47

48 CCM Process - Stage 4 Review participation agreement with patients and confirm their understanding. In person or via phone Record in the electronic chart that CCM was explained and written consent obtained to accept or decline services, from whom (name of clinician), receive electronic care plan, and of the right to stop CCM services at any time. 48

49 CCM Process - Stage 5 Create and document a Comprehensive Care Plan. As appropriate, share the Comprehensive Care Plan with other clinicians and providers. Created through the office visit, AWV or IPPE 49

50 CCM Process - Stage 6 Provide the patient with the written or electronic copy of the comprehensive care plan. Using the patient portal is a low cost way to deliver the care plan, so encourage all participating patients (or their designated caregiver) to join and become familiar with use of the portal. 50

51 CCM Process - Stage 7 Document the Time Spent Set up a system that can keep track of time spent on non-face-to-face services provided, including: phone calls and with patient; time spent coordinating care (by phone or other electronic communication) with other clinicians, facilities, community resources, and caregivers; and time spent on prescription management/medication reconciliation. 51

52 CCM Process - Stage 8 Termination from program Document death, transfer of patient to another clinician, or termination from the CCM 52

53 E/M, Annual Wellness and Subsequent Wellness Visit 53

54 RHC Changes Effective April 1, 2016 Effective April 1, 2016, RHCs, are required to report the appropriate HCPCS code for each service line along with the revenue code, and other required billing codes. Example: Revenue Code HCPCS Code Charge Amount $75 54

55 Evaluation and Management Consider the requirements: History History of Present Illness Review of Systems Past, Family, Social History Examination 1995 or 1997 Documentation Guidelines Medical Decision Making Number of Diagnosis Complexity of Data Risk 55

56 E/M to Comprehensive Care Plan HPI elements Same for chronic conditions Stable or worsening? Same for review of systems Past, Family, Social History Add Psychosocial -? Add Environmental -? Medication Reconciliation 56

57 E/M to Comprehensive Care Plan Examination Head to Toe Mental Cognitive Psychosocial -? Functional -? 57

58 E/M to Comprehensive Care Plan Medical Decision Making Based upon reason for visit Data reviewed Risk Example: Patient has two stable chronic conditions, labs ordered, medication refilled Medical Decision Making = Low 58

59 E/M to Comprehensive Care Plan Medical Necessity is the driving force for selection of an evaluation and management code. Do we consider the key elements of an examination? Do we consider counseling or coordination of care? 59

60 E/M to Comprehensive Care Plan Counseling or Coordination of Care Acceptable examples of documenting time during a patient visit: "75% of the 45 minute visit was spent counseling the patient on the prognosis of..." "45 minutes of the 60 minute visit was spent counseling the patient on the prognosis of..." minutes minutes minutes 60

61 Annual Wellness to CCP RHCs Annual Wellness Visit (AWV) may be billed as a visit if it is the only medical service on that day with a RHC practitioner. If AWV is furnished on the same day as a medical visit, it is not separately billable as an RHC visit. IPPE is separately billable 61

62 Annual Wellness to CCP Annual Determine Health Risk Assessment Demographic Data Self-Assessment of health status Psychosocial risks Behavioral risks Activities of Daily Living Establish a list of current providers Establish medical and family history CCP Social History 62

63 Annual Wellness to CCP Annual (continued) Review potential risk factors for depression Review functional ability Ability to perform ADL Fall risk Hearing impairment Home safety Assess Height, weight, BMI, blood pressure CCP Complete Exam (including chronic conditions) Cognitive Impairment 63

64 Annual Wellness to CCP Annual (continued) Establish written screening schedule United States Preventive Services Task Force Establish risk factor conditions Health education: Fall prevention Nutrition Physical Activity Tobacco-use Weight loss 64

65 Annual Wellness to CCP If completed at annual to include CCP, will also need: Medication Management Expected Outcome Expected Goals Measurable Treatment Symptom Management and planned interventions 65

66 Considerations Medical necessity Three chronic conditions. RHC AIR payment the same Looking at detailed data submitted RHC multiple visit regulations AWV and medical = 1 billable visit IPPE and medical = 2 billable visits Mental and medical = 2 billable visits 66

67 CCM Frequently Asked Questions 67

68 CCM Frequently Asked Questions Can the 20% co-insurance be waived? You must bill for the co-insurance. If the patient is unable to pay, refer to your organization s charity care policy for further instruction. 68

69 CCM Frequently Asked Questions Does the provider need to see the patient before CCM starts? The provider must make the referral to CCM. This can be done during an E/M visit, AWV or IPPE. 69

70 CCM Frequently Asked Questions Can staff complete the consent paperwork and other documents after the provider discusses CCM program and obtains patients consent? The administrative staff within the clinic or the Care Coordinator can complete consent, care plan and initial encounter elements once the provider sees the patient. 70

71 CCM Frequently Asked Questions How long is the Patient Authorization/ Signed Informed Consent form good for? The consent is valid indefinitely and does not have to be renewed, however, it will expire and become invalid if patient sees an alternate provider for their CCM services. 71

72 CCM Frequently Asked Questions What if CCM is interrupted and patient does not have an encounter for one month? Consent is still active. If 20 minutes not documented for that month, you would not bill that month for CCM. 72

73 CCM Frequently Asked Questions Can staff complete the consent paperwork and other documents after the provider discusses CCM program and obtains patients consent? The auxiliary staff within the clinic or Care Coordinator can complete consent, care plan and initial encounter elements once the provider sees the patient. 73

74 CCM Frequently Asked Questions Does the patient need to sign their care plan? They must receive a copy of their care plan and you must document in the EHR that they received a copy. 74

75 CCM Frequently Asked Questions Are there services that can t be billed by a provider while billing for CCM? Transitional Care Management (CPT and 99496) Home Healthcare Supervision (HCPCS G0181) Hospice Care Supervision (HCPCS G0182) End-Stage Renal Disease services (CPT ) 75

76 CCM Frequently Asked Questions RHC practitioner discusses CCM with patient during an E&M, IPPE or AWV, patient doesn t decide until following week that he wants the service, can patient get or wait until next E&M? If patient comes back a week later and says they thought about it and they want to sign up for CCM services, as long as discussion was documented they can complete process by signing the consent form. 76

77 CCM Frequently Asked Questions Will the CCM reimbursement rate change throughout the year? The rate is set annually and will be applied to CCM claims from January 1 st December 31 st. There is no geographic adjustment. 77

78 CCM Frequently Asked Questions Does CCM have to be billed on a claim with an RHC visit? CCM services can be billed alone or on the same claim as a billable visit. 78

79 CCM Frequently Asked Questions Will CCM cost such as software and management oversight be included in the RHC cost report? Cost incurred should be included on the Medicare Cost Report: CMS will be adding a line to report costs associated with CCM costs Reimbursed on the fee schedule Excluded from RHC cost per visit Separately identify and track CCM costs 79

80 CCM Frequently Asked Questions How does a beneficiary revoke his or her consent? CMS does not specify the manner in which a beneficiary must revoke consent. If a beneficiary gives written consent to a second provider to furnish CCM service, that will revoke the consent given to the first practitioner. 80

81 CCM Frequently Asked Questions Does the 20 minutes count if patient gets lab work and staff contacts the patient to explain the results and provides recommendations based upon those results? This would be considered part of the CCM services. 81

82 CCM Frequently Asked Questions Each time we speak to the patient, does that count towards the 20 minute time? If the conversation is between the patient and the clinical staff and the conversation addresses the chronic conditions then it can count towards the 20 minutes Face-to-face (if patient presents to office & no billable visit) Phone 82

83 CCM Frequently Asked Questions Since this is a timed code, would you expect to see start and stop times documented in order to support the 20 minutes? Time must be documented as either total time OR start/stop times. 83

84 CCM Frequently Asked Questions Can CCM services be subcontracted out to a case management company? What if the clinical staff employed by the case management company are located outside of the United States? 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. 84

85 CCM Frequently Asked Questions Can I bill CPT if the beneficiary dies during the service period? CPT 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. 85

86 Questions? Thank You! 86

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