Transitional Care Management We provide these services a-la-carte...

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1 Transitional Care Management We provide these services a-la-carte... Initial Patient Outreach* This must be done within 2 days of the patient s discharge from the hospital. During this call patient s medications are reviewed as well as the post-discharge instructions. Face-To-Face Visit This must be done within 7-14 days of the patients discharge from the hospital. We can schedule this appointment in the provider s Practice Management System, flag preventive services, and support patient attendance through live reminder calls. Interim Patient Support Throughout the 30-day post-discharge time period, we assist the patient in locating community resources, with scheduling/coordinating other physician appointments or testing, we educate the patients on their condition and much more. Missouri - St. Louis Metro $ $ Missouri - Kansas City $ $ Missouri - The Rest of MO $ $ choose the options that best fit your practice. *Timely access to hospital discharge data is required Elizabeth.Chandler@h3ci.com

2 Chronic Care Management This is a Medicare-approved program designed to assist patients with the management of multiple chronic conditions. Eligible patients are identified by our team of RN s, LPN s, CNA s and CMA s begin regular, often weekly, calls with CCM enrolled patients. During each call, our team collects patient status, symptoms, medication compliance, medication reconciliations and physiological data used to aid the physician in the ongoing development of treatment plans. Medicare beneficiary w/ 2+ Chronic Conditions Medication Reconciliations & Compliance Guidance HIPAA-Compliant Care Plan Creation & Physician Approval Let our team of nurses and other clinical staff support your providers in providing Chronic Care Management to your patients. We can support you in achieving all of the services required to meet CMS requirements to bill CCM. Reimbursement for CCM in Missouri: Missouri - St. Louis Metro $41.93 Missouri - Kansas City Metro $41.96 Missouri - The Rest of MO $39.87 Proactive Patient Engagement and Outreach Coordination w/ Full Care Team...expand your services today! Elizabeth.Chandler@h3ci.com

3 January 18, 2017 Frequently Asked Questions about Physician Billing for Chronic Care Management Services This document answers frequently asked questions about billing chronic care management (CCM) services to the Physician Fee Schedule (PFS) under CPT codes 99487, and The CCM codes describe time spent per calendar month by clinical staff. Who qualifies as clinical staff? If the billing physician (or other billing practitioner) furnishes services directly, does their time count towards the clinical staff time required to bill CCM? Practitioners should consult the CPT definition of the term clinical staff. 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. Of course, other staff may help facilitate CCM services, but only time spent by clinical staff can be counted. If the billing practitioner provides the clinical staff services themselves, the time of the billing practitioner may be counted as clinical staff time. 2. Do the times listed for the work of the billing practitioner mean that the billing practitioner must spend that amount of time each month, in addition to the clinical staff time in the code descriptors, in order to bill CCM? No, these times should be considered like the typical times for evaluation & management (E/M) office visits. They are assumed times, established through physician survey by the American Medical Association when the codes were created and valued, for how much time the billing practitioner spends himself or herself each month, but are not exact times. The billing practitioner s time could be spent in activities such as directing clinical staff; personally performing clinical staff activities; or in the case of complex CCM, performing moderate to high complexity medical decision making. 3. 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? Complex CCM (CPT 99487, 99489) includes moderate to high complexity medical decision-making by the billing practitioner during the service period, an activity that cannot be subcontracted to any other individual. Similarly, regular ( non-complex ) CCM (CPT 99490) assumes 15 minutes of work by the billing practitioner. All CCM service codes are valued to include ongoing oversight, management, collaboration and reassessment by the billing practitioner consistent with the included service elements. This work cannot be delegated or subcontracted to any other individual. A billing practitioner may arrange to have other aspects of the CCM service 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 and there is clinical integration among the care team members. If there is little oversight by the billing practitioner or a lack of clinical integration between a third party providing CCM and the billing practitioner, we do not believe CCM could

4 January 18, 2017 actually be furnished and therefore the practitioner should not bill for CCM. 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. 4. 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? It is our expectation 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). In order to bill for complex CCM (CPT or 99489), the comprehensive care plan must be established or substantially revised, and the billing practitioner must personally perform moderate to high complexity medical decision-making during the service period, as the CPT code descriptors include these services. 4. What date of service should be used on the physician claim and when should the claim be submitted? The CCM service period is one calendar month. For non-complex CCM (CPT 99490), CMS expects the billing practitioner to continue furnishing services during a given month as medically necessary after the minimum clinical staff time threshold to bill is met (see #3 above). Practitioners may report CPT at the conclusion of the service period, or after completion of the minimum clinical staff service time. When the time 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. For complex CCM (CPT 99487, 99489), practitioners should report the service code(s) at the conclusion of the service period because in addition to specified clinical staff service time, the code(s) include moderate or high complexity medical decision-making (determined by the problems addressed by the reporting practitioner during the month). 5. What place of service (POS) should be reported on the physician claim? CCM is priced in both facility and non-facility settings. The billing practitioner should report the POS for the location where he or she would ordinarily provide face-to-face care to the beneficiary. Our goal is to pay under the PFS for CCM furnished to beneficiaries in any care setting, but to pay an accurate rate that reflects the resource costs of the practitioner him or herself. We welcome information from stakeholders regarding how often they furnish CCM to beneficiaries who reside or remain in facility settings during part or all of the service period, what kind of facilities, and how often the resources and staff of the billing practitioner are used rather than facility resources and staff in the provision of CCM. We recognize that there could be many different arrangements based on the location(s) of the beneficiary during the month and individual practice patterns.

5 January 18, Can I bill for CCM services furnished to beneficiaries in skilled nursing facilities, nursing facilities, assisted living or other facility settings? Yes. CCM is priced in both facility and non-facility settings. The POS on the claim should be the location where the billing practitioner would ordinarily provide face-to-face care to the beneficiary, see #5 above. 7. Is a new patient consent form required each calendar month or annually? 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. 8. Is Medicare now paying separately under the PFS for remote patient monitoring services described by CPT code or similar CPT codes? CPT continues to be bundled with other services for payment under the PFS. As per CPT guidance, CPT codes 99090, and other codes cannot be billed during the same service period as CPT However as discussed in the CY 2015 PFS final rule (79 FR 67727), analysis of patient-generated health data and other activities described by CPT or similar codes may be within the scope of CCM services, in which case these activities would count towards the minimum minutes of qualifying care per month that are required to bill CCM services. But in order to bill CCM services, such activity cannot be the only work that is done all other requirements for billing CCM must be met in order to bill the appropriate code, and time counted towards billing CCM services cannot also be counted towards billing other codes. 9. If a practitioner arranges to furnish CCM services to his/her patients incident to using a case management entity outside the billing practice, does the billing practitioner need to ever see the patient face-to-face? Yes, for new patients or patients not seen within a year prior to the commencement of CCM services, CCM must be initiated by the billing practitioner during a comprehensive E/M visit, annual wellness visit (AWV) or initial preventive physical exam (IPPE). This face-to-face visit is not part of the CCM service and can be separately billed to the PFS, but is required for the specified patients before CCM services can be provided directly or under other arrangements. The billing practitioner must discuss CCM with the patient at this visit. While informed patient consent does not have to be obtained during this visit, it is an opportunity to obtain the required consent. The face-toface visit included in transitional care management (TCM) services (CPT and 99496) qualifies as a comprehensive visit for CCM initiation. Levels 2 through 5 E/M visits (CPT through 99215) also qualify; CMS is not requiring the practice to initiate CCM during a level 4 or 5 E/M visit. However CPT codes that do not involve a face-to-face visit by the billing practitioner or are not separately payable by Medicare (such as CPT 99211, anticoagulant management, online services, telephone and other E/M services) do not meet the requirement for the visit that must occur before CCM services are furnished. If the practitioner furnishes a comprehensive E/M, AWV, or IPPE and does not discuss CCM with the patient at that visit, that visit cannot count as the initiating visit for CCM. 10. Do face-to-face activities count as billable time? CCM includes, in large part, activities that are not typically or ordinarily furnished face-to-face with the beneficiary and others, such as telephone communication, review of medical records and test results, and coordination and exchange of health information with other practitioners and providers. Prior to separate payment for CCM, these activities were primarily included in the payment for face-

6 January 18, 2017 to-face visits (though they usually occurred before or after), and we tend to refer to them as nonface-to-face activities because generally, they are such. If these activities are occasionally provided face-to-face for convenience or other reasons, the time may be counted towards a CCM service code(s). CCM also includes activities such as patient education or motivational counseling, that are frequently provided to patients either in person or non-face-to-face (such as by phone). If the practitioner believes a given beneficiary would benefit or engage more in person, or for similar reasons recommends a given beneficiary receive certain CCM services in person, they may still count the activity as billable time. In all cases, the time and effort cannot count towards any other code if it is counted towards CCM. 11. Medicare and CPT allow billing of E/M visits during the same service period as CCM. If an E/M visit or other E/M service is furnished the same day as CCM services, how do I allocate the total time between CCM and the other E/M code(s)? CCM services are E/M services. Time or effort that is spent providing services within the scope of the CCM service, on the same day as an E/M visit or other E/M service that Medicare and CPT allow to be reported during the CCM service period, can be counted towards CCM codes, as long as it is not counted towards other reported E/M code(s). We note that time and effort cannot be counted twice, whether face-to-face or non-face-to-face, and Medicare and CPT provisions specify certain codes that can never be billed during the CCM service period (see below). 12. Medicare and CPT specify that CCM and TCM cannot be billed during the same month. Does this mean that if the 30-day TCM service period ends during a given calendar month and a qualifying amount of time is spent furnishing CCM services on the remaining days of that calendar month, CCM service codes cannot be billed that month to the PFS? The CCM service code(s) could be billed to the PFS during the same calendar month as TCM, if the TCM service period ends before the end of a given calendar month and a qualifying amount of time is spent furnishing CCM services subsequently during that month. (Also for complex CCM, there must be moderate or high complexity medical decision-making by the billing practitioner during the remainder of the month). 13. Are there any other services that cannot be billed under the PFS during the same calendar month as CCM? Yes, Medicare does not allow the CCM service codes to be billed during the same service period as home health care supervision (HCPCS G0181), hospice care supervision (HCPCS G0182) or certain ESRD services (CPT ) because the comprehensive care management included in CCM could significantly overlap with these services. Complex and non-complex CCM cannot be billed for a given beneficiary the same service period (the practitioner would bill one or the other, depending what services were furnished). Also see CPT coding guidance for a list of additional codes that cannot be billed during the same month as the CCM service codes. There may be additional restrictions on billing for practitioners participating in a CMS model or demonstration program; if you participate in one of these separate initiatives, please consult the CMS staff responsible for these initiatives with any questions on potentially duplicative billing.

7 January 18, Can I bill for CCM if the beneficiary dies during the service period? The CCM service code(s) can be billed if the beneficiary dies during the service period, as long as the required service time for the code(s) was met that calendar month and all other billing requirements are met. 15. Will practitioners be able to use an acceptably certified electronic health record (EHR) technology for which certification expires mid-year in order to bill for CCM? For example, can they use technology certified to the 2011 Edition to fulfill the scope of services required to bill CCM in 2015 once this technology no longer bears a 2011 Edition certified mark? Yes. Under the CCM scope of services, practitioners must record certain patient health information in a structured format, using technology certified to the Edition(s) of certification criteria that is acceptable for the EHR Incentive Programs as of December 31st of the year preceding each CCM payment year. In certain years, this may mean that practitioners can fulfill the scope of services requirement using multiple Editions of certification criteria. For instance, for payment in 2015, practitioners may use technology certified to either the 2011 or 2014 Edition of certification criteria to meet the EHR scope of service requirements, as both Editions could be used to meet the requirements of the EHR Incentive Programs as of December 31, This remains true for a given PFS payment year even after ONC-Authorized Certification Bodies (ONC-ACBs) have removed the certifications issued to technology certified to a given acceptable edition (e.g., the 2011 Edition for CCM payment in 2015) as a result of the relevant criteria being removed from the Code of Federal Regulations. Thus, practitioners using an acceptable EHR technology that loses its certification midyear may still use that technology to fulfill the certified EHR criteria for billing CCM during the applicable payment year. 16. Does the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L ) affect the billing rules for CCM services? No, Section 103 of the MACRA codifies payment broadly for chronic care management services under the PFS, authorizing PFS payment after January 1, 2015, for CCM services furnished by physicians and the non-physician practitioners that Medicare generally recognizes to furnish and bill for E/M services (physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives). It does not impact the current billing and payment rules for CCM. It provides that provision of an AWV or IPPE in advance shall not be a condition of payment for CCM services, which is consistent with our current policy. It also provides that payment shall not be duplicative of other Medicare payments, consistent with the rules we have implemented to date regarding duplicative payment for CCM. 17. If a beneficiary declines to receive CCM services or does not provide consent, or if other conditions of payment for CCM are not met, can the practitioner bill the beneficiary? No, the beneficiary must provide the required consent and all other Medicare conditions of payment must be met in order to bill Medicare or the beneficiary for CCM. If the beneficiary does not provide consent or if other conditions for payment are not met, the practitioner cannot bill Medicare or the beneficiary for CCM. Medicare would consider any CCM services furnished to the beneficiary as included in payment for the face-to- face visit(s) furnished to the beneficiary. As we noted in the CY 2014 PFS final rule with comment period (78 FR ), payment for non- face-to-face care

8 January 18, 2017 management services was previously bundled into payment for face-to-face visits, and we did not revalue these visits under the PFS to account for separate payment of CCM services. We also note that CCM would be considered a reasonable and necessary covered Medicare service, so it would not be appropriate to issue the beneficiary an Advance Beneficiary Notice of Noncoverage (ABN). 18. If I provided more than 20 minutes of CCM services, can I bill more than one unit or more than one line item of CPT in the service period to account for this time? CPT code (non-complex CCM) describes a minimum number of minutes of service (there is no maximum). Therefore, the practitioner may only bill one unit and one line item of CPT per calendar month. Also only one practitioner can bill CCM per service period, and must report either complex or non-complex CCM (not both). Practitioners should report complex CCM (under CPT 99487, 99489) if the higher service times for complex CCM are met, the problems addressed by the billing practitioner during the month require moderate to high complexity medical decision-making, and the comprehensive care plan is established or substantially revised. 19. Will Medigap cover the beneficiary cost sharing for CCM? Yes. If services are covered under Medicare Part B, Medigap insurers do not have authority to deny the coinsurance, copayments or other benefits that are payable on behalf of the beneficiary under the provisions of the Medigap insurance contract. Private insurers providing standardized Medigap plans agree to accept a notice of Medicare payment as a claim for the payment of benefits under the Medigap plan, unless the Medigap policy itself has a deductible that has not yet been met (e.g., high deductible Plan F). 20. Will Medicaid cover the beneficiary cost sharing for CCM for dually eligible beneficiaries? The Centers for Medicare & Medicaid Services (CMS) wishes to ensure that Medicare-Medicaid dually eligible beneficiaries have access to CCM services. The majority of dually eligible beneficiaries (approximately 64%, or 7 of the 11.4 million dually eligible beneficiaries) are Qualified Medicare Beneficiaries who will not be responsible for CCM cost sharing. For Qualified Medicare Beneficiaries, Medicaid is responsible for deductibles/coinsurance for Medicare services, including CCM, even if the services are not covered in the State Plan. However, as permitted by federal statute, most states limit payment of Medicare cost sharing to the lesser-of Medicaid or Medicare rates. If the service is not covered in the State plan, states can set other reasonable payment limits, approved by CMS, for the service. The net effect of these policies is that many states pay little to none of the Medicare deductible/coinsurance, leaving practitioners to absorb the costs for Qualified Medicare Beneficiaries. In states where there would be coverage of some or all of the beneficiary cost sharing, practitioners need to be enrolled as Medicaid providers to be paid for the Medicare cost sharing; however, Medicare automatically crosses over claims to states for dual eligible beneficiaries, so practitioners need not submit their own bill. 21. Where can I find more guidance on CCM billing requirements? Fact Sheets and other materials on CCM are available on the CMS website on the Physician Fee Schedule (PFS) page under the Care Management hyperlink at ( CCM materials are also available on the Office of Minority Health web page (

9 January 18, 2017 Materials for CCM in federally qualified health centers (FQHCs) and rural health centers (RHCs) are available on the FQHC web page ( Health-Centers-FQHC-Center.html). The governing regulations for CCM are the CY 2014, CY 2015 and CY 2017 PFS final rules, which are also available on the CMS Physician Fee Schedule web page. CCM payment rules were initially finalized in the CY 2014 and CY 2015 PFS final rules, and were significantly revised to reduce administrative burden and improve payment accuracy in the CY 2017 PFS final rule. Regarding intersection with CMS care coordination models and demonstrations, please consult the CMS staff responsible for those projects. You may also direct questions to your Medicare Administrative Contractor.

10 CONNECTED CARE THE CHRONIC CARE MANAGEMENT RESOURCE The Centers for Medicare & Medicaid Services (CMS) has adopted separately billable codes to improve payment and access to chronic care management (CCM) services for Medicare beneficiaries with two or more serious chronic conditions. Health care professionals have an opportunity to be separately paid for important services while improving your Medicare patients self-management, health outcomes, and patient satisfaction.

11 By using the CCM codes below, your practice can be separately reimbursed for important care management services that it provides to fee-for service Medicare patients with two or more chronic conditions that are expected to last at least 12 months and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Your patients will gain a team of dedicated health care professionals who can help them plan for better health and stay on track. Services such as monthly check-ins and ready access to their care team can help them connect the dots and improve their care coordination. If you re not offering CCM services, you may be missing out on the opportunity to provide the connected care your Medicare patients need and want, while simultaneously growing your practice. Some of the tools and resources available to you to successfully implement and bill for CCM services include: Information about CCM and its benefits Billing and eligibility information Frequently asked questions Resources to help educate your patients about CCM Information about upcoming webinars where you can learn more and ask questions To access these resources and to learn more about CCM, visit: go.cms.gov/ccm CMS Product No , March 2017

12 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Chronic Care Management Services Changes for 2017 What is CCM? Chronic Care Management (CCM) services by a physician or nonphysician practitioner (Physician Assistant [PA], Nurse Practitioner [NP], Clinical Nurse Specialist [CNS], Certified Nurse-Midwife [CNM]) and their clinical staff, per calendar month, for patients with multiple (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. Only 1 practitioner can bill CCM per service period (month). The included services are: Use of a Certified Electronic Health Record (EHR) Continuity of Care with Designated Care Team Member Comprehensive Care Management and Care Planning Transitional Care Management Coordination with Home- and Community-Based Clinical Service Providers 24/7 Access to Address Urgent Needs Enhanced Communication (for example, ) Advance Consent Key Improvements for 2017 Increased payment and additional codes (Table 1) - For 2016, the single CCM code paid approximately $42. Now there are 3 codes and payment can range from approximately $43 to over $141, depending on how complex a patient s needs are. A given patient can receive either regular (often referred to as non-complex ) CCM or complex CCM during a service period if applicable (not both) The difference between complex and non-complex CCM is the amount of clinical staff time, the extent of care planning, and the complexity of the problems addressed by the billing practitioner during the month CPT codes, descriptions and other data only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/HHSAR apply. CPT only copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. ICN December 2016 Please note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare).

13 Reduced requirements associated with initiating care, and increased payment when extensive initiation work is necessary (Table 1) Initiating visit only required for new patients or those not seen within a year prior to the commencement of CCM (previously all patients required an initiation visit) Increased payment for CCM-related work by the billing practitioner during initiating visits (Add-On Code G0506 can be billed in addition to the initiating visit service code when the billing practitioner personally performs extensive assessment and CCM care planning beyond the usual effort for the initiating visit code) Significantly reduced administrative burden (reduced payment rules for billing the services, Table 2) Improved alignment with CPT coding language for administrative simplicity, focus on timely sharing and availability of health information rather than use of specific electronic technology, simplified patient consent, reduced documentation rules General supervision in Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), however only CPT is payable in these settings (complex CCM is not payable) and there is no add-on code/separate payment for initiating visits TABLE 1. SUMMARY OF 2017 CCM CODING CHANGES BILLING CODE CCM (CPT 99490) Complex CCM (CPT 99487) Complex CCM Add-On (CPT 99489, use with 99487) CCM Initiating Visit* Add-On to CCM Initiating Visit (G0506) PAYMENT (NON- FACILITY RATE) CLINICAL STAFF TIME $43 20 minutes or more of clinical staff time in qualifying services CARE PLANNING Established, implemented, revised, or monitored $94 60 minutes Established or substantially revised $47 Each additional 30 minutes of clinical staff time Established or substantially revised Page 2 BILLING PRACTITIONER WORK Ongoing oversight, direction, and management Assumes 15 minutes of work Ongoing oversight, direction, and management + Medical decision-making of moderate-high complexity Assumes 26 minutes of work Ongoing oversight, direction, and management + Medical decision-making of moderate-high complexity Assumes 13 minutes of work $44-$ Usual face-to-face work required by the billed initiating visit code $64 N/A Established Personally performs extensive assessment and CCM care planning beyond the usual effort described by the separately billable CCM initiating visit *(Annual Wellness Visit [AWV], Initial Preventive Physical Examination [IPPE], Transitional Care Management [TCM], or Other Qualifying Face-to- Face Evaluation and Management [E/M]) CPT only copyright 2016 American Medical Association. All rights reserved.

14 TABLE 2. SUMMARY OF CCM SERVICES CHANGES FOR 2017 CCM Requirement Changes for 2017 Initiating Visit Certified EHR and other electronic technology requirements Continuous Relationship with Designated Care Team Member Comprehensive Care Management and Care Planning Transitional Care Management 24/7 Access to Address Urgent Needs Advance Consent Now only required for new patients or patients not seen within 1 year prior to commencement of CCM Extra payment for extensive initiating services by the CCM practitioner (G0506) Certified EHR still required to standardize formatting in the medical record of core clinical information (demographics, problems, medications, medication allergies), but certified technology no longer required for other CCM documentation or transitional care management documents No specific technology requirements for sharing care plan information electronically within and outside the practice, and fax can count, as long as care plan information is available timely (meaning promptly at an opportune, suitable, favorable, useful time) Individuals providing CCM after hours no longer required to have access to the electronic care plan, as long as they have timely information Remove standards for formatting and exchanging/transmitting continuity of care document(s) Continue to encourage and support the use of certified technology and increased inter-operability, but code-level conditions of Medicare Physician Fee Schedule (PFS) payment may not be the best means of accomplishing this. Practitioners are likely to transition to advanced electronic technologies due to incentives of the Quality Payment Program, independent of CCM rules. Improved alignment with CPT language for administrative simplicity Improved alignment with CPT language for administrative simplicity and appropriate caregiver inclusion No longer specify format of the care plan copy that must be given to the patient (or caregiver if appropriate) Electronic technology use standards relaxed (see above) Improved alignment with CPT language for administrative simplicity Clinical summaries used in managing transitions renamed continuity of care document(s) Electronic technology use standards relaxed (see above) Improved alignment with CPT language Clarifying the required access is for urgent needs Verbal instead of written consent is allowed (but must still be documented in the medical record, and the same information must be explained to the patient for transparency) CPT only copyright 2016 American Medical Association. All rights reserved. Page 3

15 This educational product was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This educational product was prepared as a service to the public and is not intended to grant rights or impose obligations. This educational product may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network, MLN Connects, and MLN Matters are registered trademarks of the U.S. Department of Health & Human Services (HHS). Check out CMS on: Twitter LinkedIn YouTube Page 4

16 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Chronic Care Management Services The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions. Please note: The information in this publication applies only to the Medicare Fee-For-Service Program (also known as Original Medicare). This fact sheet provides background on payable CCM service codes, identifies eligible practitioners and patients, and details the Medicare PFS billing requirements. Beginning January 1, 2017, the CCM codes are: CCM CPT Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care 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 CPT codes, descriptions and other data only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/HHSAR apply. CPT only copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. ICN December 2016

17 Complex CCM CPT 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 CPT 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 in conjunction with Do not report for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month. CCM (sometimes referred to as non-complex CCM) and complex CCM services share a common set of service elements (summarized in Table 1). 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. Practitioner Eligibility Physicians and the following non-physician practitioners may bill CCM services: Certified Nurse Midwives Clinical Nurse Specialists Nurse Practitioners Physician Assistants Only one practitioner may be paid for CCM services for a given calendar month. This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both). NOTE: CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care. 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. CPT only copyright 2016 American Medical Association. All rights reserved. Page 2

18 Supervision The CCM codes (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision 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 Patients with multiple (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 are eligible for CCM services. Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications or repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language. There is a need to reduce geographic and racial/ethnic disparities in health through provision of CCM services. Table 2 provides a number of resources for identifying and engaging subpopulations to help reduce these disparities. The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex CCM during a given service period, not both. Examples of chronic conditions include, but are not limited to, the following: Alzheimer s disease and related dementia Arthritis (osteoarthritis and rheumatoid) Asthma Atrial fibrillation Autism spectrum disorders Cancer Cardiovascular Disease Chronic Obstructive Pulmonary Disease Depression Diabetes Hypertension Infectious diseases such as HIV/AIDS Initiating Visit For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visit with the billing practitioner). This initiating visit is not part of the CCM service and is separately billed. Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]). G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation. Patient Consent Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. 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) CPT only copyright 2016 American Medical Association. All rights reserved. Page 3

19 Informed patient consent need only be obtained once prior to furnishing CCM, or if the patient chooses to change the practitioner who will furnish and bill CCM. CCM Service Elements - Highlights The CCM service is extensive, including 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. Although patient cost-sharing applies to the CCM service, most patients have supplemental insurance to help cover CCM cost sharing. Also CCM may help avoid the need for more costly services in the future by proactively managing patient health, rather than only treating severe or acute disease and illness. Table 1 summarizes the CCM service elements, which apply to both complex and non-complex CCM unless otherwise specified. CCM services are typically provided outside of face-to-face patient visits, and focus on characteristics of advanced primary care such as a continuous relationship with a designated member of the care team; patient support for chronic diseases to achieve health goals; 24/7 patient access to care and health information; receipt of preventive care; patient and caregiver engagement; and timely sharing and use of 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. This means a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31st of the calendar year preceding each Medicare PFS payment year. For more information, visit EHRIncentivePrograms. Comprehensive Care Plan A person-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed) Provide the patient and/or caregiver with a copy of the care plan Ensure the electronic care plan is available and shared timely within and outside the billing practice to individuals involved in the patient s care Care planning tools and resources are publicly available from a number of organizations (see Resources in Table 2) Comprehensive Care Plan A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements: Problem list Expected outcome and prognosis Measurable treatment goals Symptom management Planned interventions and identification of the individuals responsible for each intervention Medication management Community/social services ordered A description of how services of agencies and specialists outside the practice will be directed/coordinated Schedule for periodic review and, when applicable, revision of the care plan Page 4

20 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 health care professionals in the practice to address urgent needs regardless of the time of day or day of week Ensure continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments 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, or secure electronic patient portal) Comprehensive Care Management Systematic assessment of the patient s medical, functional, and psychosocial needs System-based approaches to ensure timely receipt of all recommended preventive care services Medication reconciliation with review of adherence and potential interactions Oversight of patient self-management of medications Coordinating care with home and community based clinical service providers Transitional Care Management Manage transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after an emergency department visit, or facility discharge Timely create and exchange/transmit continuity of care document(s) with other practitioners and providers Concurrent Billing The billing practitioner cannot report both complex CCM and non-complex CCM for a given patient for a given calendar month. CCM cannot be billed during the same service period as HCPCS codes G0181/G0182 (home health care supervision/hospice care supervision), or CPT codes (certain End-Stage Renal Disease services). CCM should not be reported for services furnished during the 30-day transitional care management service period (CPT 99495, 99496). Complex CCM and prolonged Evaluation and Management (E/M) services cannot be reported the same calendar month. Consult CPT instructions for additional codes that cannot be billed concurrent with CCM. There may be additional restrictions on billing for practitioners participating in a CMS sponsored model or demonstration program. Time that is reported under or counted towards the reporting of a CCM service code cannot also be counted towards any other billed code. Payment CMS pays for CCM services separately under the Medicare PFS. To find payment information for a specific geographic location by code, access the Medicare PFS Look-Up tool at Medicare-Fee-for-Service-Payment/PFSlookup. CCM and Other CMS Advanced Primary Care Initiatives The CCM service codes provide payment of care coordination and care management for a patient with multiple chronic conditions within the Medicare Fee-For-Service Program. Medicare will not make duplicative payments for the same or similar services for patients with chronic conditions already paid for under the various CMS advanced primary care demonstration and other initiatives, such as the Comprehensive Primary Care (CPC) Initiative. For more information on potentially duplicative billing, consult the CMS staff responsible for demonstration initiatives. CPT only copyright 2016 American Medical Association. All rights reserved. Page 5

21 Table 1. CCM Service Summary Initiating Visit Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visit not required), for new patients or patients not seen within 1 year prior to the commencement of CCM services. Structured Recording of Patient Information Using Certified EHR Technology Structured recording of demographics, problems, medications, and medication allergies using certified EHR technology. A full list of problems, medications, and medication allergies in the EHR must inform the care plan, care coordination, and ongoing clinical care. 24/7 Access & Continuity of Care Provide 24/7 access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week Continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments Comprehensive Care Management Care management for chronic conditions including systematic assessment of the patient s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications. 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. 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. A copy of the plan of care must be given to the patient and/or caregiver. Management of Care Transitions Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers Home- and Community-Based Care Coordination Coordination with home- and community-based clinical service providers Communication to and from home- and community-based providers regarding the patient s psychosocial needs and functional deficits must be documented in the patient s medical record Enhanced Communication Opportunities Enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods. Patient Consent Inform the patient of the availability of CCM services; that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month) Document in the patient s medical record that the required information was explained and whether the patient accepted or declined the services Medical Decision-Making Complex CCM services require and include medical decision-making of moderate to high complexity (by the physician or other billing practitioner). Page 6