Chronic Care Management FAQs

Let us help you navigate the New Medicare Regulations for Payment. 

 

Determining Patient Eligibility
 

Q. Which patients are eligible for CCM? 

A. Medicare beneficiaries diagnosed with 2+ chronic conditions expected to persist at least 12 months (or until death).  
 

Q. Is there a list of chronic diseases that are eligible for CCM reimbursement? Are there any chronic diseases that are not eligible for CCM reimbursement?

A. CMS has stated that “chronic” conditions are not limited to the definition from the American Medical Association’s CPT definition, nor are they limited to the dataset upon which the code is based. CMS has published a list of 17 chronic conditions which are available from MDR revolution along with the related ICD 9 codes. There is no list of excluded conditions, either.
 

Q. Will Medicare patients pay a portion of the CCM fee? Is this also one of the reasons a patient’s consent is needed ahead of time?

A. Yes, Physicians must obtain beneficiary’s informed consent to CCM. Like all Medicare Part B services beneficiaries will be responsible for a monthly coinsurance of about $8. Beneficiaries must also be informed that their personal health information will be shared.  
 


Billing Requirements
 

Q. Who can bill for CCM?  

A. CCM is a fee-for-service billing code. It cannot be billed by more than one physician at the same time for the same patient.

Physicians (regardless of specialty), advanced practice registered nurses, physician assistants, clinical nurse specialists, and certified nurse midwives (or the provider to which such individual has reassigned his/her billing rights). Other non-physician practitioners and limited-license practitioners are not eligible.
 

Q. What practice standards must be satisfied to bill for CCM? 

A. The physician’s practice must have an EHR certified to either the 2011 or 2014 requirements of Medicare’s EHR Incentive Program for the preceding calendar year. 
 

Q. Are physicians who participate in Medicare ACOs eligible for CCM payments?

A. Physicians and practices who are participating in ACOs are eligible to bill for Chronic Care Management (CCM).
 

Q. Are there services a physician must furnish to a beneficiary prior to billing for CCM for that beneficiary? 

A. While CMS strongly recommends that a physician furnish an annual wellness visit (HCPCS G0438, G0439) or an initial preventive physical exam (G0402) to the beneficiary, there is no prerequisite service to bill for CCM. 


Q. Can CCM services be billed when a Medicare Patient is in a nursing home or other Long Term Care (LTC) type of facility (excluding Hospice)?

A. No, it cannot be billed at all if the patient is receiving care billed under the TCM, home health care supervision, hospice care supervision, or is in ESRD or certain demonstrations testing care homes.
 

Q. Do Primary Care Physicians (PCPs) need to be part of a Patient-Centered Medical Home or similar in order to be able to bill for CCM services? 

A. No.  
 

Q. What constitutes a billable unit of CCM services? 

A. CCM services can be billed at the end of each month, provided that at least 20 minutes of non-face-to-face care management services are furnished and documented in the EHR during that time period.  
 

Q. Can CCM services (e.g. Nurse Practitioner, Registered Dietitian) be outsourced to another organization or do these services need to be provided by an employee of the physician’s practice?

A. The services required under CCM can be performed by employees of the practice and/or independent contractors, as long as they are under the direct supervision of the physician who is billing Medicare.  
 


Managing CCM Services
 

Q. How is the 20 minutes of service counted? 

A. Time may be aggregated to total 20 minutes or more, but if two persons are furnishing services at the same time, only the time spent by one individual may be counted. Time of less than 20 minutes over a 30-day period may not be rounded up to meet this requirement. If a beneficiary is wearing a 24 hour heart monitor this time does not count either. 
 

Q. What level of supervision is required for clinical staff providing CCM? 

A. To count toward the 20-minute requirement, clinical staff must furnish services consistent with the “incident to” requirements, except direct supervision (i.e., physician present in some suite of offices and immediately available to provide assistance or direction) is not required. Instead, the services may be provided under general supervision (no physical presence requirement), and a physician other than the one billing may provide such supervision. 



Documentation & Electronic Health Record Requirements 
 

Q. Are outputs from RevUp (e.g. text messages, care plans, etc.) required to be included in the patient’s EHR record for CCM reimbursement?   

A. The RevUp software platform will provide the documentation necessary for the physician to bill CMS for CCM services. The information will be posted electronically in an appropriate location in the EHR.  
 

Q. What level of certification is required for an EHR?

A. The CCM-billing practice must have an EHR certified to either the 2011 or 2014 requirements of Medicare’s EHR Incentive Program for the preceding calendar year.  
 

Q. How will providers prove that their patient has consented to receiving CCM services?  Will electronic consent be acceptable? 

A. There are three steps to the process: 

1) The physician must document that chronic care management services were explained and offered to the patient, noting the patient’s decision to accept these services. 

2) A written or electronic copy of the care plan must be provided to the beneficiary and this would also be recorded in the beneficiary’s electronic medical record. 

3) The patient must positively affirm in a document that they are agreeing to receive these services.

Consent by the patient for the CCM services must be obtained at least every 12 months.  
 

Q. What is the Payment for CCM services?

A. Here's the calculation for a national average CCM payment for a non-facility-based physician. The CY 2015 conversion factor (CF) is $35.8013. Payment for all physician claims in PFS is determined primarily by the Relative Value Units (RVUs) for Work, Physician Expense, and Malpractice.  

Payment = [(Work RVU) + (PE RVU) + (MP RVU)] x CF

For CCM, payment = (.61 + .57  +  .04) x 35.8013  =  $43.68  

Geography, professional shortage areas, and other modifiers will also be factored-in to the final Medicare payment amount for any specific physician as well as any budget sequestration adjustments.   

CMS has used several different estimates of the monthly payment in their press releases.  Here's the press release with the $42 estimate which we have used: 

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-07-03-1.html
 

Q. Can any physician practice currently performing many of these services just bill?

A. Assuming the practice is already providing chronic care management services, there are several functions that the office staff are not currently performing, but most importantly is the assurance of the compliance with the regulations and the documentation of the 20 minutes of the non-face-to face care management services that is required in the EHR.

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