PYA Principal Denise Hall and PYA Manager Lori Baker presented an educational session, “Chronic Care Management in Post-Acute/LTC Setting” to members of The Vision Group during The Society for Post-Acute and Long-Term Care Medicine’s (AMDA) Annual Conference.
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The Current Healthcare Environment
Sick
Patient
Acute
Care
Post-
Acute
Care
Sick
Patient
Chronic
Care
Home
Chronic Care =
Acute
Exacerbation
Medical
Necessity
Denials
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Fast Facts
Source: https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx, (March 10, 2016).
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Fast Facts
Source: https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx, (March 10, 2016).
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Reimbursement Differences
Traditional PAC
Professional Services
National average non-
facility reimbursements:
CPT 99305 - $131.401
CPT 99308 - $69.821
Chronic Care
Management Services
National average non-
facility additional
reimbursement per
beneficiary per month:
$40.822
1) Centers for Medicare & Medicaid Services, “Physician Fee Schedule” (March 10, 2016). www.cms.gov/apps/physician-fee-schedule
2) Centers for Medicare & Medicaid Services, “Physician Fee Schedule” (March 11, 2016). www.cms.gov/apps/physician-fee-schedule
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Potential CCM Gross Annual Revenue
Description Low Range High Range Formula
Annual Number of Unique Patients1 1,742 1,742 A
Percent of Patients Covered by Medicare1 29.12% 29.12% B
Annual Number of Unique Medicare Patients 507 507 C = A*B, Rounded
Percent Qualifying for CCM2 34.3% 68.6% D
Annual Number of Unique CCM Patients 174 348 E = D*C, Rounded
Average Annual Months to Bill per Patient3 6 12 F
CCM Monthly Payment4 $40.82 $40.82 G
Annual Gross Revenue for Family Medicine Physician $42,658 $170,464 H = (G*F)*E
1 Per the MGMA Cost and Revenue Survey: 2015 Report Based on 2014 Data specific to the specialty of family medicine (median results).
Includes traditional and Medicare Advantage.
2 CMS.gov - County Level Multiple Chronic Conditions (MCC) Table: 2012 Prevalence, National Average is 68.60% (our upper end). Low range
is based on 20% less than the average.
3 Based on The National CCM Survey 2015, three-quarters of respondents believed that patients would be eligible for CCM services for 6
months or less during a calendar year. Low- and high-end ranges consider this response.
4 Reimbursement amount from the CY 2015 Physician Fee Service Final Rule; assumes 100% of unique patients are covered via traditional
reimbursement. Medicare Advantage reimbursement may vary.
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CCM Components
At least 20 minutes of clinical staff time, directed by a
physician or other qualified healthcare professional,
per calendar month:
Multiple (two or more) chronic conditions expected to last at least 12
months, or until the death of the patient
Chronic conditions place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline
Comprehensive care plan established, implemented, revised, or
monitored
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Qualifications
Furnished by clinical staff
Delegating physician determines individual is qualified
Permissible under state law
Non-clinical staff administrative time does not count
Under physician/non-physician general supervision
Vs. usual direct supervision requirement for “incident to” billing
No physical presence requirement
Supervisor does not have to be billing provider
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Asynchronous Exception Monitoring
“Practitioners who engage in remote monitoring of patient
physiological data of eligible beneficiaries may count the
time they spending reviewing the reported data towards
the monthly minimum time for billing the CCM code, but
cannot include the entire time the beneficiary spends under
monitoring or wearing a monitoring device.”
Source: Centers for Medicare & Medicaid Services, “Frequently Asked Questions about Billing Medicare for Chronic Care Management Services” at 5 (May 7, 2015).
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/Payment-Chronic-Care-Management-Services-FAQs.pdf.
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Warning: 20+ Minutes
20+ minutes non-face-to-face care management services
per calendar month
20 minutes can be aggregated, but not rounded up
May be provided by different individuals, but cannot count
double for two staff members providing services at the
same time
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Warning: No “Double Dipping”
Cannot bill for CCM and any of the following during same
30-day period:
Transitional care management (99495 and 99496)
Home healthcare supervision (G0181)
Hospice care supervision (G0182)
ESRD services (90951-90970)
CMS will not pay for more than one provider to furnish
CCM in each calendar month
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Key Considerations
1. Eligible providers
2. Eligible beneficiaries
3. Consent to receive CCM
4. Five specific capabilities
5. Non-face-to-face services
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1. Eligible Providers
Physician (any specialty), APRN, PA, CNS,CNMW
Not an RHC/FQHC service
No qualifying services (e.g., annual wellness visit)
However, must be initiated with face-to-face visit
No practice accreditation (e.g., PCMH)
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2. Eligible Beneficiaries
2+ chronic conditions
No definitive list – CMS maintains the Chronic Condition
Warehouse3 (CCW) for approximately 60 specified chronic and
potentially disabling conditions, but this is not an exclusive list and
CMS may recognize other conditions
Expected to last at least 12 months, or until the death of
the patient; place patient at significant risk of death, acute
exacerbation/decompensation, or functional decline
3) https://ccwdata.org/web/guest/condition-categories
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3. Written Consent
Provider cannot bill for CCM unless and until it secures
beneficiary’s written consent
Consent must be obtained during or after face-to-face
visit
If beneficiary revokes consent, cannot bill for CCM after
then-current calendar month
Must be documented in certified EHR (see below)
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4. Five Specified Capabilities
Provider must demonstrate following capabilities:
A. Use of certified EHR for specified purposes
B. Electronic care plan
C. Beneficiary access to care
D. Transitions of care
E. Coordination of care
Submission of claim = attestation of capabilities
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A. Use of Certified EHR
Must utilize “CCM-certified technology” for specified
purposes in providing CCM
the edition(s) of the meaningful use certification criteria in use as
of 12/31 of preceding year
Not required to be meaningful user of certified EHR
technology
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B. Electronic Care Plan
Maintain regularly updated electronic care plan for
beneficiary
Based on physical, mental, cognitive, psychosocial, functional,
and environmental (re)assessment of beneficiary’s needs
Inventory of resources and supports
Addresses all health issues (not just chronic conditions)
Congruent with beneficiary’s choices and values
Preparation and updating of care plan is not a component
of CCM; may bill as separate E&M code if requirements
satisfied (e.g., AWV)
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Access to Electronic Care Plan
1. Electronically accessible 24/7 to all care team members
furnishing CCM services billed by the practice
E.g., remote access to EHR, web-based access to care
management application, web-based access to HIE – not
facsimile
2. “Must electronically share care plan information as
appropriate with other providers” caring for patient
E.g., secure messaging, participation in HIE – not facsimile
3. Provide paper or electronic copy to beneficiary
Must be documented in certified EHR
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C. Beneficiary Access to Care
1. Means for beneficiary to access provider in the practice* on
24/7 basis to address acute/urgent needs in timely manner
2. Beneficiary’s ability to get successive routine appointments
with designated practitioner or member of care team
3. Enhanced opportunities for beneficiary-provider (or
caregiver-provider) communication by telephone +
asynchronous consultation methods (e.g., secure
messaging, internet)
*person whose time is counted in 20 minutes of non-face-
to-face care management services per month
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D. Transitions of Care
Capability and capacity to do the following:
Follow up after ER visit
Provide transitional care management
Coordinate referrals to other clinicians
Share information electronically with other clinicians as
appropriate
Summary care record and electronic care plan
No specific manner of transmission required
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E. Coordination of Care
Coordinate with home- and community-based clinical
service providers to meet beneficiary’s psychosocial
needs and functional deficits
Home health and hospice
Outpatient therapies
DME suppliers
Transportation services
Nutrition services
Communications with these providers must be
documented in certified EHR
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5. Non-Face-to-Face Services
Types of service (non-exclusive)
Performing medication reconciliation, oversight of beneficiary self-
management of medications
Ensuring receipt of all recommended preventive services
Monitoring beneficiary’s condition (physical, mental, social)
Documentation
Date and time (start/stop?)
Person furnishing services (with credentials)
Brief description of services
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Billing Rules
Date of service = day on which meet 20 minute
requirement (or any day thereafter thru end of month)
May bill after date of patient’s death, but only if met 20-minute
requirement prior to that date
Site of service = location at which billing practitioner
normally would see patient for face-to-face visit
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Creation and Operations
Opportunities for partnership (physicians, health systems)
Impact on relationship with referring physicians
Legal structure
Regulatory compliance issues
Billing
Marketing implications
Operationalizing impacts
Hiring vs. contracting supervising MD, impact on
relationships with current physicians and staff
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Option 1 for Delivering CCM
HHA/SNF-employed Qualified Provider (QP) performs QP-required
elements of service with HHA/SNF staff performing other elements:
HHA/SNF must have Part B billing number (HHA/SNF = Part A)
QP may be part-time employment limited to CCM services
QP reassigns billing rights to HHA/SNF; HHA/SNF submits claim to Part
B; HHA/SNF responsible for maintaining documentation
Structure arrangement to satisfy Stark Law except, Anti-Kickback Statute
safe harbor
Not permitted in states prohibiting corporate practice of medicine
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Option 2 for Delivering CCM
HHA/SNF-contracted QP performs QP-required elements of service
with HHA/SNF staff performing other elements:
HHA/SNF must have Part B billing number (HHA/SNF – Part A)
Contract may be with individual QP or physician practice
Scope of contract may be limited to CCM services
QP reassigns billing rights to HHA/SNF; HHA/SNF submits claim;
HHA/SNF responsible for maintaining documentation
Structure arrangement to satisfy Stark Law except, Anti-Kickback Statute
safe harbor
Fair market value for QP payments based on wRVU analysis
Option in states prohibiting corporate practice of medicine
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Option 3 for Delivering CCM
Independent individual QP or physician practice contracts with
HHA/SNF to provide non-QP-required elements:
Option for QP/practice that lacks staff and/or infrastructure to provide
support services
QP/practice pays HHA/SNF flat rate or per-service rate (based on wRVU
analysis)
Structure arrangement to satisfy Stark Law except, Anti-Kickback Statute
safe harbor
QP/practice submits claim; QP/practice responsible for maintaining
documentation
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Option 4 for Delivering CCM
Hospital/SNF/community mental health center with partial
hospitalization program contracts with HHA/SNF to provide non-QP
required elements:
Option for facility that wants to use its employed/contracted QPs to
furnish CCM services, but lacks staff and/or infrastructure to provide
support services
QP/practice pays HHA/SNF flat rate or per-service rate (based on wRVU
analysis)
Structure arrangement to satisfy Stark Law except, Anti-Kickback Statute
safe harbor
Facility submits claim (based on reassignment from QP/practice); facility
responsible for maintaining documentation
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Option 5 for Delivering CCM
ACO contracts with HHA/SNF to coordinate its CCM program and/or
provide non-QP required elements:
Option for ACO that wants to support participating physicians who lack
staff and/or required infrastructure to provide support services
ACO pays HHA/SNF flat rate or per-service rate (based on wRVU
analysis)
ACO-participating physicians submit claims and responsible for
maintaining documentation
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Questions
35. PERSHING YOAKLEY & ASSOCIATES, P.C.
800.270.9629 | www.pyapc.com
Denise Hall
Principal
dhall@pyapc.com
Lori Baker
Manager
lbaker@pyapc.com
Editor's Notes
LOri
Lori
Lori
Beneficiary must acknowledge provider has explained:
Nature of CCM services and how they are accessed
Only one provider at a time can furnish CCM
Beneficiary’s PHI will be shared with other providers for care coordination purposes
Beneficiary may stop CCM services at any time by revoking consent, effective at end of then-current calendar month
Beneficiary responsible for co-payment/deductible
Structured recording of the following consistent with 45 CFR 170.314(a)(3)-(7)
Patient demographic information
Problem list
Medications and medication allergies
Creation of structured summary care record consistent with 45 CFR 170-314(e)(2)
Not required to use specific tool or service to transmit summary care record for care coordination purposes
“whenever a scope of service element references a health or medical record, CCM certified technology must be used to fulfill that . . . requirement . . . .”
The following must be documented in beneficiary’s record using CCM certified technology:
Beneficiary consent
Provision of care plan to beneficiary
Communication to and from home- and community-based providers regarding beneficiary’s psychosocial needs and functional deficits (care coordination)
Typical Items Included in Care Plan
Problem list; expected outcome and prognosis; measurable treatment goals
Symptom management and planned interventions (including all recommended preventive care services)
Community/social services to be accessed
Plan for care coordination with other providers
Medication management (including list of current meds and allergies; reconciliation with review of adherence and potential interactions; oversight of patient self-management)
Responsible individual for each intervention
Requirements for periodic review/revision
Use of Electronic Technology Tool
“must electronically capture care plan information”
“use some form of electronic technology tool or services in fulfilling the care plan element”
“certified EHR technology is limited in its ability to support electronic care planning at this time”
“practitioners must have flexibility to use a wide range of tools and services beyond EHR technology now available in the market to support electronic care planning”