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CPAs & ADVISORS
Kentucky Primary Care Association – 2015 Conference
Thursday, November 12, 2015
CHRONIC CARE MANAGEMENT – WHAT DOES THIS MEAN TO YOU?

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The following information was used as a visual aid during a presentation/training
session led by a BKD, LLP advisor. This content was not designed to be utilized
without the verbal portion of the presentation. Accordingly, information included on
these slides, in some cases, are only partial lists of requirements, recommendations,
etc. and should not be considered comprehensive. These materials are being issued
with the understanding they must not be considered legal advice.

3.  CMS Rulings
 Chronic Care Management (CCM) Services
Defined
 CCM Reimbursement and Revenue
Potential
 CCM Billing Requirements
 CCM Scope of Services Elements –
Highlights
 Electronic Health Record (EHR)
Requirements
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6. CMS MEDICARE PHYSICIAN FEE SCHEDULE
CY 2015 FINAL RULE
• In 2014, CMS finalized policies to
establish separate payments for
CCM services.
• Payment for CCM services was
effective, beginning January 1,
2015.
• Did not include FQHC and RHC
providers.
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7. CMS CY 2016 FINAL RULE
CMS CY 2015 Final Rule states:
“In considering CCM payment for RHCs and FQHCs, we believe that the non-face-to-face time
required to coordinate care is also not captured in the RHC AIR or the FQHC PPS payment,
particularly for the rural and/or low-income populations served by RHCs and FQHCs. Allowing
separate payment for CCM services in RHCs and FQHCs is intended to reflect the additional
resources necessary for the unique services that are required in order to furnish CCM services that
are not already captured in the RHC AIR or the FQHC PPS payment.”
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8. CMS CY 2016 FINAL RULE (cont’d)
CMS CY 2016 Final Rule states:
“This final rule we proposed to provide an additional payment for the costs of CCM services that are not
already captured in the RHC AIR or the FQHC PPS payment, beginning on January 1, 2016. Services that
are currently being furnished and paid under the RHC AIR or FQHC PPS payment methodology will not be
affected by the ability of the RHC or FQHC to receive payment for additional services that are not
included in the RHC AIR or FQHC PPS.”
“The requirements we proposed for RHCs and FQHCs to receive payment for CCM services are consistent
with those finalized in the CY 2015 PFS final rule with comment period for practitioners billing under the
PFS… We proposed to establish payment, beginning on January 1, 2016, for RHCs and FQHCs who furnish
a minimum of 20 minutes of qualifying CCM services during a calendar month to patients with multiple
(two or more) chronic 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.”
“We proposed that an RHC or FQHC can bill for CCM services furnished by, or incident to, an RHC or
FQHC physician, nurse practitioner, physician assistant, or certified nurse midwife for an RHC or FQHC
patient once per month, and that only one CCM payment per beneficiary per month can be paid.”
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9. CHRONIC CARE MANAGEMENT DEFINED
CMS defines CCM as:
“Chronic care management services
furnished to patients with multiple (two
or more) chronic conditions expected to
last at least 12 months, or until the death
of the patient, that place the patient at
significant risk of death, acute
exacerbation/decompensation or
functional decline.”
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10. CHRONIC DISEASE DEFINED
• A chronic disease is a long-lasting condition that can be controlled but
not cured.
• Examples of chronic conditions: (not all-inclusive)
 Alzheimer’s disease and related dementia
 Asthma
 Cancer
 Chronic obstructive pulmonary disease
 Diabetes
 Heart failure
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11. CCM CPT CODE ASSIGNMENT
Chronic Care Management (CPT 99490)
• According to the CMS Chronic Care Management Fact Sheet,
CPT 99490 is defined as:
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12. CCM REIMBURSEMENT
• Payment for CCM services:
 First quarter of 2015, the national average payment rate was $42.91.
 Rate is not subject to a geographic adjustment.
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13. POPULATION HEALTH – CASE STUDY
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• The Centers for Medicare & Medicaid
Services (CMS) recognizes care
management as one of the critical
components of primary care that
contributes to better health and care for
individuals, as well as reduced spending.
• According to the Centers for Disease
Control and Prevention (CDC), about 2/3
of Medicare beneficiaries – 117 million
people – have 2+ chronic diseases.

14. CLINIC REVENUE POTENTIAL
Potential Revenue Per Provider
• Based on the national data, the table below calculates the revenue potential for a single
provider billing for CPT 99490. If a provider performs CCM services for their census of
qualified Medicare patients, their additional revenue potential is substantial.
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15. ELIGIBLE PROVIDERS
Who can furnish CCM?
• Physicians and non-physician practitioners (NPP), such as nurse practitioners,
physician assistants, clinical nurse specialists and certified midwives, can
furnish and bill Medicare for CCM, but only to the extent permitted under their
scope of practice.
• Other NPP, such as clinical psychologists and social workers, are not eligible to
bill.
• Qualifying “clinical staff” defined by “incident to” rule.
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16. CCM AND “INCIDENT TO” RULES
“Incident To” Rules:
• CMS expects that many CCM services will be furnished “incident to” a physician’s services
• Direct Supervision vs. General Supervision
 CMS requires only general supervision criteria for CCM incident-to services
performed by auxiliary/ancillary staff for Part B providers.
 CMS requires direct supervision criteria for CCM incident-to services performed by
RHC and FQHC auxiliary/ancillary staff.
• All other requirements related to “incident to” services would still apply to CCM services.
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17. ELIGIBLE MEDICARE BENEFICIARY
A qualified Medicare beneficiary must have:
• Two or more chronic conditions
 No definitive list
• Must have a chronic condition expected to last at least 12 months, or until the
death of the patient, and places patient at significant risk of death, acute
exacerbation/decompensation or functional decline
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18. MEDICARE BENEFICIARY AGREEMENT
• Getting a Medicare beneficiary agreement includes, but is not limited to:
 Informing the patient of the availability of CCM services and obtaining his or
her written agreement to have the services provided.
 Advising the patient that only one provider can furnish and be paid for CCM
in a calendar month.
 Informing the patient of the right to stop CCM services at any time.
 Explaining that cost sharing applies.
 FQHCs – coinsurance
 RHCs – coinsurance and deductibles
 Documenting in the patient’s medical record that all of the CCM services
were discussed and offered to the patient.
 Noting in the patient’s medical record the patient’s decision to accept or
decline these services.
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19. CCM BILLING REQUIREMENTS
• CMS requires:
 Billing providers to furnish either an
Annual Wellness Visit (AWV), Initial
Preventive Physical Exam (IPPE) or a
comprehensive Evaluation and
Management (E/M) visit to the patient
prior to billing the CCM service.
 Must initiate CCM services as part of
one of those exams/visits.
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20. CCM BILLING REQUIREMENTS (cont’d)
• Codes/services that cannot be reported during the same month as CCM:
 Home health and hospice care supervision (HCPCS codes G0181 – G0182)
 End-stage renal disease service (CPT codes 90951 – 90970)
 Transitional care management (CPT codes 99495 – 99496)
o CCM services can 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 at least 20 minutes of
qualifying CCM services are subsequently provided during that month. However, CMS
expects that the majority of the time, CCM and TCM will not be billed during the same
calendar month.
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21. CCM SCOPE OF SERVICE
• CCM service requirements include, but are
not limited to, the following:
 Access to care management services,
24 hours a day, 7 days a week
 Continuity of care
 Care management for chronic conditions
 Creation of a patient-centered care plan
 Management of care transitions
 Coordination with home- and community-
based clinical service providers
 Enhanced communication opportunities
for patients and/or caregivers
 Electronic capture and sharing of care plan
information
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22. CCM SCOPE OF SERVICE DEFINED
• Access to care management services, 24 hours a day, 7 days a week
 Providing patients with a means to make timely contact with providers or clinical staff to
address urgent chronic care needs, regardless of the time of day or day of the week.
• Continuity of care
 The patient must be able to get successive routine appointments with a designated
provider or a member of the care team.
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23. CCM SCOPE OF SERVICE DEFINED (cont’d)
• Care management for chronic conditions
 Systematic assessment of a patient’s medical, functional and psychosocial needs
 System-based approaches to ensure timely receipt of all recommended preventive care
services
 Medication reconciliation
 Oversight of patient self-management of medications
• 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
 It is a comprehensive plan of care for all health issues
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24. CCM SCOPE OF SERVICE DEFINED (cont’d)
• Creation of a patient-centered care plan (cont’d)
 A patient-centered care plan typically includes, but is not limited to:
 Problem list
 Expected outcome and prognosis
 Measurable treatment goals
 Symptom management
 Planned interventions and identification of the individuals responsible for each
intervention
 Medication management
 Community/social services ordered
 Schedule for periodic review and revision of plan (when applicable)
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25. CCM SCOPE OF SERVICE DEFINED (cont’d)
• Management of care transitions
 Referrals to other clinicians
 Follow-up after a patient visit to an emergency department
 Follow-up after a patient is discharged from a hospital, skilled nursing facility or other
healthcare facility
• Coordination with home- and community-based clinical service providers
 To ensure appropriate support of a patient’s psychosocial needs and functional deficit
 Communication to and from these providers must be documented in the EHR using CCM
certified technology
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26. CCM SCOPE OF SERVICE DEFINED (cont’d)
• Enhanced communication opportunities for patients and/or caregivers
 Communication with the provider regarding the beneficiary’s care through telephone,
secure messaging, secure internet or other asynchronous non-face-to-face consultation
methods (subject to HIPAA)
• Electronic capture and sharing of care plan information
 Available on a 24/7 basis to all clinical staff within the clinic who are furnishing CCM
services and whose time counts toward the time requirement for billing the CCM code
 Shared electronically (other than by facsimile), as appropriate, with other providers who
are furnishing care to the beneficiary
 Must provide the patient with a written or electronic copy of the care plan and document
in the EHR that this was done
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27. CCM ELECTRONIC TECHNOLOGY REQUIREMENTS
• Technology requirements include, but are
not limited to:
 A certified EHR must be used for the
recording of demographic information,
health-related problems, medications and
medication allergies; a clinical summary
record; and other scope of service
requirements that reference a health or
medical record.
 Must use technology certified to the
edition(s) of certification criteria that is, at a
minimum, acceptable for the EHR incentive
programs as of December 31st of the year
preceding each CCM payment year.
 CMS refers to technology meeting these
requirements as “CCM Certified Technology.”
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28. CCM ELECTRONIC TECHNOLOGY REQUIREMENTS (cont’d)
Scope of service elements that require CCM certified technology:
 Structured recording of demographics, problems, medications, medication allergies and
using CCM certified technology.
 Document the beneficiary’s care plan provisions in the EHR using CCM certified
technology.
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29. CCM ELECTRONIC TECHNOLOGY REQUIREMENTS (cont’d)
Scope of service elements that require CCM certified technology (cont’d)
 Structured clinical summaries using CCM certified technology
 Not required to use a specific tool or service to exchange/transmit
clinical summaries, as long as they are transmitted electronically
 Clinical summaries cannot be faxed
 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
 Document the beneficiary’s written consent and authorization in the EHR using CCM
certified technology
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31. CONCLUSION
• The new rule from CMS allowing
reimbursement for CCM services is a huge
change that will allow physicians to:
 Improve patient care for Medicare
beneficiaries dealing with chronic diseases
 Now get paid for work they are already doing
to care for chronically ill patients
 Potentially increase revenue for their health
center providers
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33. 600 N. Hurstbourne Parkway
Louisville, Kentucky 40252-0127
Office: 502.581.0435
Fax: 502.581.0723
www.bkd.com
Jacqueline R. Todd-Washington,
BSM
Managing Consultant
jwashington@bkd.com
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DISCLAIMER
The information contained in this presentation is not
intended to cover all situations or all rules and policies.
Reimbursement laws, regulations and policies are subject
to change.

36. THANK YOU
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