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Reimbursing Chronic Care Management


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CMS has finally made chronic care management is reimbursable. Learn how your PCMH and care coordination efforts can now be billed.

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Reimbursing Chronic Care Management

  1. 1. Reimbursing Chronic Care Management (CCM) Wednesday, October 29th, 2014 Disclaimer: Nothing that we are sharing is intended as legally binding or prescriptive advice. This presentation is a synthesis of publically available information and best practices.
  2. 2. The concept has always sounded simple; reduce costs and improve care.
  3. 3. It’s been proven that Care Management of chronic disease accomplishes both, so why were Care Management programs unpopular? Lack of Payment • Most payers bundle payment for non-face-to-face interaction. Costs • Staff • Technology • Time Software Limitations • Care Management limitations in PM systems and integrated tools were lacking
  4. 4. Is there any clearer message? CMS will be reimbursing providers for Care Management services Effective January 1, 2015. CMS acknowledged that 75% of our healthcare spending is directly related to chronic conditions. It sends a clear message that the costs associated with chronic disease drives the decision to encourage care management in our society.
  5. 5. Non-face-to-face (NF2F) Often times, the following items below were viewed as bundled into the E&M codes. It has since been recognized that the items were under valued and an important part of the care management of the patient: Work that includes answering patient phone messages Work that includes answering patient electronic messages  Sorting through formulary changes Responding to labs or consultation recommendations Providing weekend coverage. Providing night emergency coverage
  6. 6. The Policy  No Longer Bundled • When billed with the following services: • E&M • AWV • IPPE • Separate payment for non-face-to-face chronic care management services for Medicare beneficiaries  Bundled • When Billed with the following services: • Home Health • Hospice • TCM • Nursing Home  Criteria • Medicare patient • Expected to live 12 months or until death • Multiple, significant chronic conditions (two or more)
  7. 7. Reimbursement Reimbursement • Roughly $42.00 • Subject to Co-Payment • Time Based- 20 Min • HCPCS Code to be released in November Submission • Once per month, per qualified patient provided that medical needs of the patient involve the following as it relates to the care plan: • Establishing • Implementing • Revising • Monitoring
  8. 8. Requirements Documentation in the patient’s medical record that all of the chronic care management services were explained and accepted by the patient • Document Time and Service Provided  A written agreement that electronic communication of the patient’s information with other treating providers is part of care coordination  Information about the availability of the services from the practitioner  A written or electronic copy of the care plan that is provided to the beneficiary and recorded in the electronic health record (EHR).
  9. 9. Stipulated Services Though it’s anticipated that there will be additional requirements forthcoming, the list below are identified as expectations for CCM: Continuity of care with a clinician or practice Care management that provides the following: • A systematic assessment of medical, functional, and psychosocial needs • A system-based approach for timely delivery of preventive services • Medication reconciliation • prescription and nonprescription • review of interactions and adherence
  10. 10. Stipulated Services The creation of an updatable patient-centered plan of care Management of all care transitions An EHR that is available 24/7 to both the the caregiver as well as the patient. Opportunities for patient-to provider communication via telephone or secure asynchronous NF2F messaging
  11. 11. Where do you begin? Identify patients that meet the minimum criteria  Begin the communication Establish your written protocols Identify the appropriate staff who comprise your clinical care management team. Pursue PCMH designation Establish your strategy
  12. 12. Q&A