CHRONIC CARE MANAGEMENT IMPLEMENTATION GUIDE
TABLE OF CONTENTS What is Chronic Care Management (CCM)?... 2 Why CCM?... 2 Clinician/Practice Benefits... 3 Patient Benefits... 4 What is Included in CCM?... 4 What Patients are Eligible for CCM?... 5 Who Can Bill for CCM?... 5 How Do I Implement CCM in My Practice? Four-step Approach... 6 Step 1 - Identify Eligible Patients and Establish Program Plan... 6 Step 2 - Educate and Enroll... 7 Step 3 - Activate and Deliver CCM... 7 Step 4 - Complete Appropriate and Effective Coding and Billing... 9 Where Can I Get Additional Information About CCM?... 11 Resources from Medicare (CMS)... 11 Forms and Tools... 12 Revenue and Return on investment (ROI) Tools... 12 Contact Us... 12 This material was prepared by HealthInsight, the Medicare Quality Innovation Network Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-CORP-18-59 1
What is Chronic Care Management? Chronic care management (CCM) is non face-to-face care coordination services done outside of the regular office visit 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. Why CCM? CCM is a critical component of care that contributes to better health outcomes and well-being for individuals and builds patient loyalty and trust. CCM offers more centralized management of patient needs and extensive care coordination among clinicians, thereby reducing hassles for clinicians, and the patients and caregivers. You are already coordinating care and CCM enables reimbursement for your time coordinating care for Medicare fee for service (part B) patients. 2
If implemented effectively, it is anticipated CCM will introduce the following benefits to your practice and your patients: Clinician/Practice Benefits Improve care coordination - CCM can help improve care coordination and health outcomes, and now clinicians will receive payment specifically in support of their provision of care using this approach. Encouraging patients, their family members and caregivers to use CCM services will give them the support they need to manage their conditions between visits. Support patient compliance and help patients and caregivers feel more connected - Some health care professionals say CCM services help improve efficiency, improve patient satisfaction and compliance, and decrease hospitalization and emergency department visits. Sustain and grow their practice - Appropriate billing for CCM services may help sustain care coordination work. Offering CCM may also provide additional resources to help your practice care for more patients in need. Better health for patients - Better outcomes for your sickest patients and less unneeded hospitalization and emergency department use. 3
Patient Benefits Patients and their caregivers 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 improves their care coordination, including improved communication and management of care transitions, referrals, and follow-ups. Patients and caregivers will receive a comprehensive care plan - The plan will help support the patient s disease control and health management goals, including physical, mental, cognitive, psychosocial, functional and environmental factors. Patients and caregivers may also receive a list of suggested resources and, if available, community services, and may be encouraged to keep track of referrals, community support and educational information. Encouraging patients and caregivers to use CCM will give them the support they need between visits - Having a regular touch point may help patients think about their health more and engage in their treatment plan. For example, becoming more conscious of taking their medications and other self-management tasks. Getting this help may also help patients stay on track and improve adherence to their treatment plan. Patients may reduce their out of pocket costs for expenses such as inpatient and skilled nursing care - A recent evaluation shows lower hospital and skilled nursing care use and lower total cost of care among patients receiving CCM services. What is Included in CCM? Medicare will reimburse for CCM time spent by a clinician or by clinical staff under the general supervision of a physician on any of the following types of activities: Providing comprehensive care management for patients outside of in-person visits, such as by phone or through secure email. CCM includes, in large part, activities that are not typically or ordinarily furnished face-to-face with the patient and others, such as telephone communication, review of medical records and test results, self-management education and support, and coordination and exchange of health information with other practitioners and health care professionals. It may also include some face-to-face interaction with the patient or other clinicians. Sharing patient s health information, including their electronic health plan, with the patient s other health care professionals (clinicians). Included in the health information should be the patient s demographics, problems, medications and medication allergies documented using certified electronic health record (EHR) technology. Managing care transitions, including providing referrals and facilitating follow-ups for patients after they are discharged. Coordinating with home- and community-based clinical service providers and documenting this activity in the patient s medical record. 4
What Patients are Eligible for CCM? Patients eligible for separately payable CCM services are Medicare and dual eligible (Medicare and Medicaid) beneficiaries with two or more chronic conditions expected to last at least 12 months or until the death of the patient, when those conditions place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. These are the only diagnostic criteria. Who Can Bill for CCM? CCM services may be billed by*: Physicians and certain non-physician practitioners (physician assistants, clinical nurse specialists, nurse practitioners and certified nurse midwives) Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Hospitals, including critical access hospitals (CAHs) *Only one physician or RHC or FQHC, and one hospital, can bill for CCM for a patient during a calendar month. 5
How Do I Implement CCM in My Practice? Four-step Approach This guide will help you develop your plan for successful CCM implementation by walking you through the following steps: Step 1 Identify eligible patients and establish program plan Step 2 Educate and enroll Step 3 Activate and deliver CCM Step 4 Complete appropriate and effective coding/billing Step 1 Identify Eligible Patients and Establish Program Plan How will you know your target CCM population? Use your EHR as a source for finding patients with two or more chronic conditions often this is a registry report or population health report. Create a list of potential CCM patients and flag them in your EHR or pull a working list for outreach it is recommended you organize the list by primary/preferred clinician. Review the list of eligible patients with clinicians and eliminate those that do not appear to be a good fit for the CCM program. Establish decision support rules in your EHR to flag CCM eligible patients for on-going identification and outreach If you have an active transitions of care process, start with patients who you are caring for using your transitional care management (TCM) process. How will you assign roles for CCM? Designate a care manager (often a nurse, but pharmacists, medical assistants or social workers can perform this role as well). Designate support roles for outreach and enrollment. Assign CCM support roles which can include the primary clinician, nurse and other staff helping with enrollment, consents, scheduling and other activities or services incident to the primary clinician. How will you capture documentation for tracking CCM time? Develop a CCM tracking system in your EHR and for billing. Develop a system for delivering CCM services to patients. Provide continuity of care for patients through a designated care team member (usually care manager) with whom the patient and caregiver can schedule appointments, and who is regularly in touch with the patient to help them manage their chronic conditions. 6
Step 2 Educate and Enroll How will you engage and educate patients about CCM and get verbal commitment to participate? Consider the following methods to engage with patients and families for CCM: Contact eligible patients through an outreach campaign send a letter to the list of eligible patients providing education around CCM, along with an invitation to participate. Make phone calls to the eligible patient list explaining the details of CCM and inviting them to participate. Review CCM with eligible patients during their evaluation and management office visit or Annual Wellness Visit (AWV) setup alerts/decision support to flag care team when seeing a CCM-eligible patients. Reach out to patients that have completed your TCM process and are stable but still chronically ill, and invite them to participate in CCM. The outreach campaign should consist of the following: Explain the value of the program and how it works. Provide summary information with the details they need to know. Explain what is included and how they can expect to interact with the care team (mostly by phone and/or patient portal) and that it should be treated like a regular visit. Explain the patient s obligation related to payment of coinsurance and deductibles see step 4 for more details. Let them know they can stop participating at any time. Explain that only one practitioner (and/or hospital) can provide CCM in a calendar month. Document receipt of verbal or written commitment from the patient in the patient chart. Step 3 Activate and Deliver CCM Create an electronic comprehensive care plan for each patient in the EHR Develop a format or template for the comprehensive care plan. Care plans should be based on a physical, mental, cognitive, psychosocial, functional and environmental assessment or reassessment, and an inventory of resources and supports. Below is an example of a specific EHR product s approach to a care plan see your product options: 7
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Provide CCM plan to patient and caregiver consider use of the patient portal to deliver the plan. Share the care plan with other clinicians as appropriate. Follow the care plan and provide regular and on-going care management for chronic conditions, including: Provide systematic assessment of the patient s medical, functional and psychosocial needs Ensure timely receipt of all recommended preventive care services Perform medication reconciliation with review of adherence and potential interaction Provide continuity of care for patients through a designated care team member with whom the patient can schedule appointments, and who is regularly in touch with the patient and caregiver to help them manage their chronic conditions. Provide patients with a way to reach your practice at any time to address urgent needs. Document time spent on CCM activities for each patient set up a system that can keep track of time spent on nonface-to-face services provided, including: Phone calls and secure messaging communication with the patient Coordination with other clinicians, facilities, community resources and caregivers Prescription management and medication reconciliation Periodically review and update the care plan with the patient. Step 4 Complete Appropriate and Effective Coding and Billing Calculate time spent on CCM for each patient monthly Verify that requirements were met for each patient each month Submit claims to the Centers for Medicare & Medicaid Services (CMS) monthly Send invoice for copay to patients receiving CCM services monthly Ensure no other conflicting codes have been billed 9
The billing codes and Medicare physician fee schedule payments for CCM services are: CCM initiating visit (these include most standard face-to-face evaluation and management visit codes as well as the AWV, Initial Preventive Physical Exam or TCM): $44-$209. CCM initiating visits are only required for new patients or those not seem within a year prior to commencing CCM. The CCM initiating visit (where applicable) is billable separate from the monthly CCM services. HCPCS G0506*: $64, add-on to the CCM initiating visit for the billing practitioner s time and effort personally providing extensive comprehensive assessment and CCM care planning to patients outside of the usual effort described by the initiating visit code. CPT 99490: $43 for 20 minutes or more of clinical staff time spent on non-complex CCM per calendar month that requires establishment, implementation, revision or monitoring of a care plan. CPT 99487*: $94 for 60 minutes of clinical staff time for complex CCM that requires establishment or substantial revision of a care plan, and moderate or high complexity medical decision making per calendar month. CPT 99489*: $47, add-on to use with CPT 99487 for each additional 30 minutes of clinical staff time for complex CCM per calendar month. *These codes are for complex CCM, which requires moderately to highly complex medical decision-making by the billing practitioner and substantial establishment or revision of the patient s care plan. They cannot be combined with CPT code 99490, since a patient s care management is either complex or not complex. Please note that Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can receive payment for CCM when CPT code 99490 is billed alone or with other payable services on a RHC or FQHC claim. RHCs and FQHCs are not currently authorized to bill codes 99487, 99489, or G0506. What services cannot be billed in the same time period as CCM? The following FAQs and answers are provided by CMS in their document FAQ about Physician Billing for CCM : 13. 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). 10
14. 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 End Stage Renal Disease (ESRD) services (CPT 90951-90970) 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. Patient s Obligation for Copayment or Deductibles The usual cost-sharing rules apply to these services, so many patients are responsible for the usual Medicare Part B cost sharing (deductible and copayment/coinsurance) if they do not have supplemental ( wrap-around ) insurance. Please note that the majority of dual eligible beneficiaries (patients with Medicare-Medicaid) are exempt from cost sharing. Medigap plans must provide wrap-around coverage of cost sharing for CCM, and most beneficiaries have Medigap or other supplemental insurance. Develop a Workflow that supports CCM Implementation Consider your workflow and who will carry out each task to support successful implementation of CCM in your practice. Where Can I Get Additional Information About CCM? Resources from Medicare (CMS) CCM Services Fact Sheet Summary overview of the CCM program CMS Connected Care: The Chronic Care Management Resource CCM Website CMS Connected Care: The Chronic Care Management Health Care Professional Toolkit 20 page toolkit on CCM Understanding and Promoting the Value of Chronic Care Management Services Presentation slides from CMS National Provider Call Care Management Services in RHCs and FQHCs: Frequently Asked Questions Includes guidance and answers to FAQs for care management services (TCM, CCM, Behavioral Health Integration, and Psychiatric Collaborative Care Model (CoCM)) specific to RHCs and FQHCs FAQ about Physician Billing for CCM Frequently asked questions specific to billing for CCM CMS Connected Care: Physician Testimonial about CCM YouTube video providing physician perspective on the value of CCM to her patients and her practice (length: 2:03) 11
Forms and Tools CCM Process Overview Graphic and CCM Process Checklist Created by the Texas Medical Foundation (TMF) Quality Innovation Network Quality Improvement Organization (QIN-QIO) Sample Care Coordination Agreement Between primary care provider and specialty practice by American College of Physicians (ACP) Patient-centered Care Plan Care plan template from the American Academy of Family Practice (AAFP) Make CCM Work for Your Practice Article published in Medical Economics providing overview of CCM and stories of practice implementations, Feb 2018 Revenue and Return on investment (ROI) Tools Basic Potential Revenue calculator Current non-complex CCM visits being performed: Estimate per patient non-complex (20 min): $43.00 Potential non-complex CCM per month: Total non-complex CCM estimate per month: Current complex CCM visits being performed: Estimate per patient complex (60 min): $94.00 Potential complex CCM per month: Total complex CCM estimate per month: Calculated ROI HealthInsight can create an ROI dashboard for you that will share your potential revenue based on patients who have not received a CCM visit. Please contact us to get this information via the formal report. Contact Us Contact a project facilitator in your state for personalized assistance or fill out our Contact Us form on our website. Nevada - (702) 384-9933 New Mexico - (505) 998-9898 Oregon - (503) 279-0100 Utah - (801) 892-0155 12