Chronic Care Management Services

Chronic Care Management Cloud ®
SPAC Chronic Care Management Physician, Patient and Pharmacy Portals ®
Mobile Chronic Care Management ®

These are Sargas International Products and are registered trademarks of SPAC International.

  • Regularly updated comprehensive patient centered plan of care (to be provided by the physician) from their EMR
  • Continuity of care through access to established care team (Patient specific doctors) for successive routine appointments
  • Scheduled preventive service and medication monitoring by our trained staff with customized mobile health applications for patients designed specifically for their chronic care physician
  • 24/7 Patient access to a care team. After business hours, our staff of clinically trained staff and care team is available for the patient to address acute chronic care needs
  • 24/7 Patient care team access (all the physicians will have access to each patient’s medication information via our cloud physician portal and pharmacy portal)
  • There is an opportunity for patients to communicate with their care team by telephone, secure messaging and other communication modalities like email, and support for 24/7
  • We help in the management of care transitions facilitated by electronic exchange of health information via our HIPAA compliant cloud portals
  • 24/7 access to medication information for care coordination for the patient’s medical team

Medicare will pay for only patients with two chronic diseases. Physicians will have to bill and collect on their own for these services. Patients will have to pay 20% co-payment for these services.


Summary of Final CCM Scope of Service Elements and Billing Requirements for CY 2015

CCM Scope of Service Element/Billing Requirement Certified EHR or Other Electronic Technology
Requirement
Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care. Structured recording of demographics, problems, medications, medication allergies, and creation of structured clinical summary records using CCM certified technology.
Access to care management services 24/7 (providing the beneficiary with a means to make timely contact with health care providers in the practice to address his or her urgent chronic care needs regardless of the time of day or day of the week). None
Continuity of care with a designated practitioner or member of the care team with whom the beneficiary is able to get successive routine appointments. None
Care management for chronic conditions including systematic assessment of the beneficiary’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 beneficiary self-management of medications. None
Creation of a patient-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. Share the care plan as appropriate with other practitioners and providers. Must at least electronically capture care plan information; make this information available on a 24/7 basis to all practitioners within the practice whose time counts towards the time requirement for the practice to bill the CCM code; and share care plan information electronically (other than by fax) as appropriate with other practitioners and providers.
Provide the beneficiary with a written or electronic copy of the care plan and document its provision in the electronic medical record. Document provision of the care plan as required to the beneficiary in the EHR using CCM certified technology.
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.
  • Format clinical summaries according to CCM certified technology.
  • Not required to use a specific tool or service to exchange/transmit clinical summaries, as long as they are transmitted electronically (other than by fax).
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 using CCM certified technology.
Enhanced opportunities for the beneficiary and any caregiver to communicate with the practitioner regarding the beneficiary’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. None
Beneficiary consent - Inform the beneficiary of the availability of CCM services and obtain his or her written agreement to have the services provided, including authorization for the electronic communication of his or her medical information with other treating providers. Document in the beneficiary’s medical record that all of the CCM services were explained and offered, and note the beneficiary’s decision to accept or decline these services. Document the beneficiary’s written consent and authorization in the EHR using CCM certified technology.
Beneficiary consent - Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month) and the effect of a revocation of the agreement on CCM services. None
Beneficiary consent - Inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month. None

Summary of CY 2017 Chronic Care Management Service Elements and Billing Requirements

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 chronic care management (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 beneficiary is able to schedule successive routine appointments.
Comprehensive Care Management- Care management for chronic conditions including systematic assessment of the beneficiary’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 beneficiary self-management of medications.
Comprehensive Care Plan
  • Creation, revision and/or monitoring (as per code descriptors) of an electronic patient-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.
  • 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 beneficiary’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 beneficiary and any caregiver to communicate with the practitioner regarding the beneficiary’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.
Beneficiary Consent
  • Inform the beneficiary 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 beneficiary’s medical record that the required information was explained and whether the beneficiary 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).

FAQ's

Since the Centers for Medicare & Medicaid Services (CMS) published its final rule on the 2015 Medicare physician fee schedule – and especially since Family Practice Management (FPM) published its article “Chronic Care Management and Other New CPT Codes” – I have been inundated with questions. I will try to answer at least some of them:

A1. The CCM scope of service includes “medication reconciliation with review of adherence and potential interactions” as well as “oversight of patient self-management of medications.” It is debatable whether time spent on the phone doing prior authorization for medications and tests or time sending in such prior authorization electronically would count for this purpose. At this point, it is probably safer not to count time spent on prior authorizations as CCM time, although CMS has not explicitly addressed the question.
A2. No. Code 99490 is for 20 minutes “per calendar month.” You cannot add time up over multiple months to report 99490.
A3. If the MSSP ACO case manager is a clinical staff person and the work that he or she does otherwise meets Medicare’s “incident to” rules relative to the physician who will be reporting 99490 (understanding that, for CCM, CMS allows “incident to” services to be provided under general, rather than direct, supervision), then his or her time may be counted toward the 20 minutes necessary to report code 99490, where appropriate.
A4. CMS has not specified what diagnosis codes should be reported with code 99490. Absent guidance to the contrary, it seems reasonable to report at least the two primary chronic care conditions for which you are providing 99490.
A5. CMS has acknowledged that the services of pharmacists may be billed “incident to” those of a physician or other qualified health care professional, such as a nurse practitioner or physician assistant, as long as all of the “incident to” requirements are otherwise met. Thus, a clinical pharmacist could be counted among the clinical staff able to provide CCM services “incident to” the services of the physician or mid-level provider under whose provider number the services will otherwise be billed to Medicare. I do not believe that Medicare recognizes clinical pharmacists as providers for purposes of billing Medicare directly under Medicare Part B or the physician fee schedule.
A6. The 2015 Medicare physician fee schedule assigns 0.61 work RVUs to code 99490.
A7. In the final rule on the 2015 Medicare physician fee schedule, in its discussion of the scope of the CCM service, CMS states, "In consultation with the patient, any caregiver, and other key practitioners treating the patient, the practitioner furnishing CCM services must create a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values." I interpret this to mean that the physician or non-physician practitioner who is nominally furnishing CCM services and, presumably, under whose provider number the services will be billed is responsible for creating the care plan. Also, CMS uses the word "practitioner" rather than "physician,” so I believe that a mid-level provider, such as a nurse practitioner or physician assistant, could acknowledge/sign the care plan if he or she created it.
A8. In the final rule on the 2014 Medicare physician fee schedule, CMS stated, "The resources required to provide care management services to patients residing in facility settings significantly overlaps with care management activities by facility staff that is included in the associated facility payment." CMS did not define "facility" beyond that. I interpret facility in this context to be any health care entity (e.g., hospital, skilled nursing facility, etc.) that receives a facility payment from Medicare.
A9. There is no current mechanism to charge Medicare more if you spend longer than 20 minutes. CPT has complex chronic care management codes that would facilitate that, and the AAFP encouraged CMS to use those codes for just this reason. However, for 2015, CMS is only recognizing and paying 99490, which is open-ended in terms of the time involved.
A10. The scope of service for CCM includes creation of a patient-centered care plan. CMS also requires that you provide a copy of that care plan to the patient. I believe CMS expects both of those things to be done before you report 99490 the first time.
A11. You will need to check with the Medicare Advantage plans in your area regarding whether or not they will pay for 99490 in 2015. My understanding is that, in general, patients in Medicare Advantage plans are entitled to the same benefits enjoyed by patients covered under traditional Medicare. However, I have heard from some family physicians that some Medicare Advantage plans do not plan to cover and pay 99490.
A12: CMS has stated in the final rule that physicians cannot bill CCM services for patients in a facility setting. CMS said, "The resources required to provide care management services to patients residing in facility settings significantly overlaps with care management activities by facility staff that is included in the associated facility payment." CMS did not define "facility" beyond that. I interpret "facility" in this context to be any health care entity (e.g., hospital, skilled nursing facility, etc.) that receives a facility payment from Medicare. If an assisted living facility is receiving Medicare facility payments for a given patient residing in that facility, I do not believe that you can report CCM for that patient.
A13: Regarding 24/7 access to care management, CMS states, "To accomplish this, the patient must be provided with a means to make timely contact with health care providers in the practice to address the patient's urgent chronic care needs regardless of the time of day or day of the week." Elsewhere, CMS states that the scope of CCM services includes "Enhanced opportunities for the beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary'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." Based on this information, 24/7 access is not necessarily defined as a phone call.
A14: As noted, CMS states, "To accomplish this, the patient must be provided with a means to make timely contact with health care providers in the practice to address the patient's urgent chronic care needs regardless of the time of day or day of the week." (Emphasis added) Thus, this access is related to "urgent chronic care needs." Medicare does not define "timely" in this context.
A15: CMS has not addressed this particular question. Code 99490 is intended to encompass a calendar month's worth of work. Box 24 on the CMS-1500 claim form does permit a "from" and "to" date, so I would consider putting the first day of the month as the "from" date and the last day of the month as the "to" date for 99490 as a line item. (I presume electronic claims would also support this approach.) Because code 99490 does encompass the entire calendar month, I would refrain from billing it until the last day of the month, in much the same way that CMS expects providers to wait until the end of the 30-day period to report transitional care management (TCM) codes.
A16: I am not aware of anything that would prohibit you from reporting 99490 in the same calendar month during which you saw the patient and reported an appropriate evaluation and management code for that encounter. The only codes of which I am aware that CMS has stated you cannot bill in addition to CCM services for a patient during the same time period are TCM services (99495 or 99496), home health care supervision (G0181), hospice care supervision (G0182), or certain end-stage renal disease services (90951-90970).

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