Chronic Care Management in Post-Acute/LTC Setting

Society for Post-Acute and Long-
Term Care Medicine Annual
Conference
Wednesday, March 16, 2016
Chronic Care Management
in a Post-Acute Care World

A Post-Acute Care World
The Current Healthcare Environment

Prepared for The Society for Post-Acute and Long-Term Care Medicine Page 2
The Current Healthcare Environment
Sick
Patient
Acute
Care
Post-
Acute
Care
Sick
Patient
Chronic
Care
Home
Chronic Care =
Acute
Exacerbation
Medical
Necessity
Denials

Fast Facts
Source: https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx, (March 10, 2016).

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

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.

What Is Chronic Care Management?
A Working Definition

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

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

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.

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

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

Key Considerations
1. Eligible providers
2. Eligible beneficiaries
3. Consent to receive CCM
4. Five specific capabilities
5. Non-face-to-face services

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)

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

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)

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

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

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)

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

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

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

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

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

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

Adding Chronic Care Management
Chronic Care Management Options

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

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

 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
safe harbor
 Fair market value for QP payments based on wRVU analysis
 Option in states prohibiting corporate practice of medicine

 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)
safe harbor
 QP/practice submits claim; QP/practice responsible for maintaining
documentation

 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)
safe harbor
 Facility submits claim (based on reassignment from QP/practice); facility
responsible for maintaining documentation

 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

Questions

PERSHING YOAKLEY & ASSOCIATES, P.C.
800.270.9629 | www.pyapc.com
Denise Hall
Principal
dhall@pyapc.com
Lori Baker
Manager
lbaker@pyapc.com

Chronic Care Management in Post-Acute/LTC Setting

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