Chronic Care Management SA MP LE Everything You Need to Finally Get Paid for These Essential Services 2016 Expert Report Expert Report Contributor: Rhonda Granja, CMC, CMIS, CMOM, CMCC
[DISCLAIMER] Coding Leader. Chronic Care Management: 2016 Expert Report is published by Coding Leader, a division of Must Have Info, Inc. Reproduction or further distribution by any means is strictly forbidden without written consent of Coding Leader, including photocopying and digital, electronic, and/or Web distribution, dissemination, storage, or retrieval. Expert Report Contributor: Rhonda Granja, CMC, CMIS, CMOM, CMCC President/Publisher: Samantha Saldukas Vice President: Lacy Gaskins Content Manager: Chris Owens, CPC Customer Relationship Specialist: Ben Lawless Coding Leader All Rights Reserved. 2016 1854 Trade Center Way, Suite 201, Naples, FL 34109 Phone: 800-767-1181 Fax: 800-767-9706 Email: info@codingleader.com Web: www.codingleader.com This report is an independent publication of Coding Leader. It is not endorsed nor has it any official connection with any other organization, insurance carrier, vendor, association, government agency or company. Reasonable attempts have been made to provide accurate content. However, of necessity, examples cited and advice given in a national report such as this must be general in nature and may not apply to a particular case. Neither the publishers, editors, board members, contributors, nor consultants warrant or guarantee that the information contained herein on coding or compliance will be applicable or appropriate in any particular situation. Chronic Care Management: 2016 Expert Report Published by Coding Leader, www.codingleader.com Page ii
Table of Contents A Note From the Publisher... iii Table of Contents... iv Break It Down to Start Getting Paid...1 So why now?... 1 What s really included... 2 Must-Haves to Nail Down Your Revenue...5 A. Nail Down These 5 Technical Specs... 6 B. Payment Tied to Qualified Providers... 10 C. Consent Key to Compliance & Payment... 13 D. Easy, Effective Care Plan That Works... 15 What to include in your Care Plan... 15 Sample Patient-Centered Care Plan... 18 E. What s Included to Meet Time Threshold... 19 Claim date makes a difference... 21 Financial Benefits for Getting It Right... 22 Sample Documents... 23 Sample Document Disclaimer... 23 Sample Patient Consent Form 1... 24 Sample Patient Consent Form 2... 26 Sample Chronic Care Management Revocation Form... 27 Online Resources... 28 Definitions Fast and Easy... 29 Index... 33 Chronic Care Management: 2016 Expert Report Published by Coding Leader, www.codingleader.com Page iv
Break It Down to Start Getting Paid Starting in January 2015, you could finally get paid an additional monthly amount for each chronic care patient you manage. This is welcome news because you re likely managing more and more patients with complex chronic illnesses as the population ages. So why now? You ve been providing these services for years and not getting paid for them. So why did the Centers for Medicare and Medicaid Services (CMS) decide it was time to reimburse you now? It has to do with Medicare s shift to emphasizing quality of care over simple quantity and CCM fits this directive. By compensating you for these essential services, you are incentivized to keep your patients healthier, which helps cut costs, reduce hospital admissions and improve medication management. Chronic Care Management CPT Definition Chronic care management services are provided when the medical and/or psychosocial needs of the patient require establishing, implementing, revising, or monitoring the care plan. Patients who receive chronic care management services have two or more chronic continuous or episodic health conditions that are 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. Code 99490 is reported when, during the calendar month, at least 20 minutes of clinical staff time is spent in care management activities. Chronic Care Management: 2016 Expert Report Published by Coding Leader, www.codingleader.com Page 1
Of course, simply submitting 99490 isn t the answer. You need to address specific regulatory requirements before you begin including getting the consent of each patient who will receive CCM services from your practice. According to Medicare, most offices that can bill for CCM don t. But once you re properly set up, CCM coding is quite straightforward. This report will walk you through the initial set up and the ongoing administration of submitting CCM claims so you can start receiving regular reimbursement for these services. What s really included To qualify for CCM reimbursement, your provider and clinical staff must spend at least 20 minutes of non-face-to-face time per month per patient managing their chronic ailments. If your clinician documents the service correctly and you properly apply CCM code 99490, Medicare will reimburse your office for this time at a rate of roughly $40 for each patient per 30-day period. This doesn t sound like much, but if you are providing CCM to 100 patients, that is an additional $48,000 per year. Patients qualify for CCM if they have two or more conditions that are expected to last at least 12 months and place the patient at risk of death, exacerbation or decompensation. According to Medicare s Chronic Care Management Services Fact Sheet, the following are examples of chronic conditions: Chronic Care Management: 2016 Expert Report Published by Coding Leader, www.codingleader.com Page 2
Alzheimer s disease Arthritis (osteoarthritis and rheumatoid) Asthma Atrial fibrillation Autism spectrum disorders Cancer Chronic Care Management: 2016 Expert Report Published by Coding Leader, www.codingleader.com Page 3 Chronic obstructive pulmonary disease (COPD) Depression Diabetes Heart failure Hypertension Ischemic heart disease Osteoporosis One example of how your practice might provide CCM: An elderly patient with multiple illnesses and dementia bound for a nursing home can have as many as 10 different doctors half of whom may be prescribing medications. Patients and their families find dealing with so many different specialists bewildering and stressful. At the same time, CMS believes that its payers spend more than two-thirds of Medicare dollars on these patients. CCM is meant to address this situation by helping to: Manage these different providers care. Ensure all medications prescribed make sense for the patient when taken together. Reduce the expense of uncoordinated services by paying one primary care physician to serves as the point of contact for all the patient s care. When your practitioner provides CCM services, he manages a patient s medical, functional and psychosocial needs. This includes things like medication management and coordinating
other therapeutic services. Your office also becomes the point of contact for patients and their caregivers not only through telephone access, but also through secure messaging, Internet or other non-face-to-face consultation. Your office has to be able to provide these services any time of day or night to qualify for CCM reimbursement. IMPORTANT: This report focuses on billing CCM to Medicare. There can be significant variations among private insurance carriers, so you should check with each of your private payers for their individual CCM requirements. Chronic Care Management: 2016 Expert Report Published by Coding Leader, www.codingleader.com Page 4
Must-Haves to Nail Down Your Revenue Many healthcare practices don t submit 99490 because they think the process is too complicated to be worthwhile. But if you break the requirements down, you may find that complying with them is easier than you think and worth the time, considering the reimbursement you ll receive. CCM involves several must-have key components, which we will discuss in more detail in subsequent chapters: A. Five technical capabilities B. Appropriate provider C. Patient Consent D. Care Plan Development E. 20+ minutes a month. Although the components of CCM listed above may seem challenging, it s a one-timeonly exercise, and if you have an EHR, you already have most of these tools available. You re probably a lot closer to successfully billing for CCM than you think. Don t let fear stop you from claiming the reimbursement that you are rightfully due. Chronic Care Management: 2016 Expert Report Published by Coding Leader, www.codingleader.com Page 5
A. Nail Down These 5 Technical Specs Before you submit a claim and expect to be paid for the CCM services you provide, you must have five technical capabilities in place and functioning: 1. Electronic Health Record (EHR): CMS requires that you use a Certified Technology. This means you must use an EHR that satisfies the certification criteria for the EHR Incentive Programs for recording of demographics, problems, medications and medication allergies. These criteria are established by CMS and the Office of the National Coordinator for Health Information Technology (ONC). For more information about certified EHR rules and requirements, see http://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms. CMS further demonstrates how your EHR will meet certain CCM service and billing requirements in a chart that you can find on page 9. Your practice also must create a Summary Care Record that you can transmit electronically for care coordination purposes. CMS does not specify exact acceptable transmission methods, but it does state that fax transmission is not acceptable. Therefore, you could use email, Internet transfer protocols, etc. 2. Electronic Care Plan: Your practitioner must develop an Electronic Care Plan based on a physical, mental, cognitive, psychosocial, functional and environmental assessment of your patients needs. The plan should address all Chronic Care Management: 2016 Expert Report Published by Coding Leader, www.codingleader.com Page 6