PYA Principal Martie Ross co-presented “Providing and Billing Medicare for Transitional and Chronic Care Management,” along with Robert Jarrin, Government Affairs Director of Qualcomm Life at the AHLA 2015 Institute on Medicare and Medicaid Payment Issues program. Together they: Briefly summarized research regarding advantages of care management services. Explained the history of Medicare policy regarding care management services. Provided detailed explanation of billing rules for transitional care management and level of reimbursement. Provided detailed explanation of billing rules for chronic care management and level of reimbursement. Highlighted unique arrangements for providing centralized care management services.

1. 1
Providing and Billing
Medicare for
Transitional and
Chronic Care
Management
3.26.2015 | 1:45 – 2:45 pm EST
3.27.2015 | 9:45-10:45 am EST
Faculty :
Robert Jarrin
Qualcomm Incorporated
rjarrin@qualcomm.com
Martie Ross
Pershing Yoakley & Associates, PC
mross@pyapc.com

2. 2
CMS FY 2015 Budget
Less than $12M (.0013%) spent on Telehealth 2013
$897.9 Billion Dollars

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Telehealth Reimbursement
• Statutory restrictions - SSA § 1834(m)
1. Live (real-time) voice and video.
2. Specific site of care as stipulated by CMS (not
including patient’s domicile)
3. Beneficiary resides in HPSA or MSA
4. Limited to specific list of services
• No reimbursement for remote patient monitoring

4. 4
2012 Proposed MPFS
• Create new payment for hospital discharge care
coordination?
– 2013 Final MPFS: Reimbursement for TCM
• Re-value E&M codes to account for non-face-to-
face care management services?
– 2015 Final MPFS: Reimbursement for CCM

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• 99495
– Face-to-face visit within 14 days; medical decision-
making of moderate complexity
– Approximately $165 non-facility; $136 facility
• 99496
– Face-to-face visit within 7 days; medical decision-
making of high complexity
– Approximately $233 non-facility; $199 facility
• May bill as RHC/FQHC service (encounter rate)
Transitional Care Management

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Qualified Professional
• Credentials
• MD and DO (regardless of specialty)
• DPM, DDS, and OD (if within scope of practice)
• Nurse practitioner, physician assistant, clinical nurse
specialist, and certified nurse midwife
• No prior relationship with patient required

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Discharged from Facility
• Inpatient acute care hospital
• Inpatient critical access hospital
• Inpatient psychiatric hospital
• Long-term care hospital
• Skilled nursing facility/CAH swing bed
• Inpatient rehabilitation facility
• Hospital outpatient observation (vs. ER visit only)
• Partial hospitalization at hospital or community
mental health center

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Discharged to Community
• Patient’s home
• Domiciliary (e.g., family member’s home)
• Nursing facility (vs. SNF)
• Assisted living facility
. . . regardless of whether receiving home health
or outpatient hospice services

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“Double-Dipping” Prohibited
Same QP cannot bill for TCM and any of the following services during
30-day post discharge period:
• 10- or 90-day global billing period following procedure
• Home healthcare oversight (G0181)
• Hospice care plan oversight (G0182)
• Care plan oversight services (99339, 99340, 99374-99380)
• Prolonged services without direct patient contact (99358, 99359)
• Anti-coagulant management (99363, 99364)
• Medical team conferences (99366-99368)
• Education and training (98960-98962, 99071, 99078)
• Telephone services (98966-98968, 99441-99443)
• End-stage renal disease services (90951 – 90970)
• Online medical evaluation services (98969, 99444)
• Preparation of special reports (99080)
• Analysis of data (99090, 99091)
• Complex chronic care coordination services (99481X , 99483X)
• Medication therapy management services (99605-99607)
• Chronic care management (99490)

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Four Key Components
1. Initial contact
2. Medication reconciliation and management
3. Face-to-face visit
4. Non-face-to-face care management services

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No. 1: Initial Contact
When and Where
• Within two business days after date of discharge
– Or two failed attempts at contact within same period
• Contact may be made at facility or any other
location, following discharge
• Requirement satisfied if face-to-face visit is
performed within same time period

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No. 1: Initial Contact
How and Who
• By direct contact, telephone, or electronic means
– Capacity for prompt interactive communication addressing
patient status and needs beyond scheduling follow-up care
• Contact may be made by:
– Qualified professional
– Licensed clinical staff under direction of QP
– Non-licensed staff if “incident to” requirements are
satisfied
• Direct supervision, i.e., QP present in office suite immediately
available to provide assistance (does not have to be same QP who
bills for TCM)
• Non-licensed staff employed by or independent contractor to QP
or entity to which QP has made reassignment

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No. 2: Medication
Reconciliation
• Must occur no later than the day of the face-to-
face service
• Medications on discharge reconciled with those
taken pre-admission
– Qualifications of reviewer same as those for initial
contact (except new med orders by provider with
prescribing authority

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No. 3: Face-to-Face Visit
When and Where
• Within 7 calendar days of discharge for 99496; 14
days for 99495 (and RHC/FQHC service)
• May be performed at hospital/other facility
following discharge
– Unless QP also bills for discharge day
• May be performed by telehealth--subject to
1834(m) restrictions

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No. 3: Face-to-Face Visit
How and Who
• No specified elements, i.e., history, physical
exam, medical decision-making
– Documentation must support level of medical
decision-making
• TCM billed under QP who performs visit
– Can bill “incident to” only if established patient seen
for established problem
– If billed under non-physician practitioner’s name,
payment = 85% of fee schedule

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No. 4: Non-Face-to-Face Care
Management Services
• List of services to be provided unless QP’s
reasonable assessment of patient indicates
particular services not needed
• No minimum number of interactions or time
spent providing services; no specified manner of
delivery; no required use of technology
• May be performed by licensed clinical staff under
QP’s general supervision

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No. 5: Non-Face-to-Face Care
Management Services
• Obtain and review discharge information
• Review need for, or follow-up on, pending
diagnostic tests and treatments
• Interact with other providers involved in patient’s
care
• Educate patient, family, guardian, and/or
caregiver
• Arrange for needed community resources
• Assist in scheduling required follow-up with
community providers and services

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No. 5: Non-Face-to-Face Care
Management Services
• Communicate with home health agencies and
other community services
• Educate patient/caregiver regarding self-
management, independent living, and activities
of daily living
• Assess and support treatment regimen
adherence and medication management
• Identify community and health resources
• Facilitate access to necessary care and services

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TCM Claims Submission
• Cannot submit claim until 30 days following
discharge:
– E.g., if discharged 01/01, submit claim on/after 01/30
– Date of service = 30 days following discharge
– Claims for other services furnished during 30-day
period may be submitted earlier
• Location of service = location of face-to-face-visit
• No specific diagnosis code required

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Potential Complications
• If two providers furnish TCM for same patient
over same time period, first provider to file claim
gets paid
• If patient admitted to facility within 30 days post-
discharge, provider has two options:
– Bill for face-to-face as E&M service based on
documentation; start over from date of second
discharge
– Bill on day 30 following first discharge, but if second
discharge within that 30 days, cannot bill TCM
associated with second discharge

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Chronic Care Management
• New reimbursement available on Medicare
Physician Fee Schedule effective 01/01/2015
• CPT 99490
• $40 per beneficiary per month for 20+ minutes
non-face-to-face care management services

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Financial Opportunity

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

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1. Qualified Professionals
• Same QPs as TCM
• No practice accreditation (e.g., PCMH)
• Not an RHC/FQHC service

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No “Double Dipping”
• Cannot bill for CCM and any of the following
during same calendar month:
– 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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No “Double Dipping”
• Participants in CMS’ Multi-Payer Advanced
Primary Care Practice Demonstration and
Comprehensive Primary Care Initiative cannot bill
CCM for attributed beneficiary
– If another practice bills for CCM for attributed
beneficiary, MAPCP/CPC payment will be recouped
– Beneficiary attributed to participating practice billing
CCM

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2. Eligible Beneficiaries
• 2+ chronic conditions
– No definitive list
– CMS Chronic Condition Warehouse - www.ccwdata.org
– Nearly 68% of all Medicare beneficiaries
• 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
– CMS stated intention that CCM be broadly available

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3. Written Consent
• Provider cannot bill for CCM unless and until it
secures beneficiary’s written consent
• 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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Elements of Written Consent
• 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

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Initiation of CCM Services
• “Billing practitioner must initiate the CCM service prior
to furnishing or billing it, during a face-to-face visit
(annual wellness visit, initial preventive physical exam,
or comprehensive E&M visit billed separately)”
February 18, 2015
CMS National
Provider Call
• “However, in light of the widespread concerns raised by
commenters about this requirement, we have changed
the requirement to a recommendation for a
practitioner to furnish an AWV or IPPE to a beneficiary
prior to billing for chronic care management services
furnished to that same beneficiary.”
2014 Medicare
Physician Fee
Schedule Final
Rule

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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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Specified Purposes – Core
Technology Capabilities
• 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

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Specified Purposes – Documentation
in Beneficiary’s Record
• Must document the following 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)

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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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“Typical” Care Plan Items
• 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

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Use of Electronic Technology Tool
• “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”

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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 practice on
24/7 basis to address acute/urgent needs
2. Means for beneficiary to get successive routine
appointments with designated practitioner or member
of care team
3. Make available enhanced opportunities for beneficiary-
provider communication by telephone + asynchronous
consultation methods (e.g., secure messaging, internet)

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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 Care
Management 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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20+ Minutes
• 20+ minutes non-face-to-face care management
services per calendar month
• Furnished by licensed clinical staff under physician/ mid-
level general supervision
– No physical presence requirement
– Supervisor does not have to be billing provider
• 20 minutes can be aggregated, not rounded up
• Cannot count double for 2 individuals providing services
at same time
• Exclusions
– Services furnished while beneficiary is an inpatient
– Services furnished on same days as E&M service

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Licensed Clinical Staff
• Furnished incident to physician services
– BUT general supervision (vs. direct supervision)
– Available by telephone; does not have to be billing
physician
• Qualifications
– Deemed competent by billing provider AND
– State-issued license to practice a healthcare
profession or certified medical assistant

45. 45
Hospital Outpatient Department
• If no “incident to” billing in hospital setting, count
licensed clinical staff time?
• CCM facility rate $9.00 less
– Physician compensated for hospital staff supervision
(vs. “incident to” supervision)
• Separately bill facility fee

46. 46
Billing for CCM
 CMS has not identified claims edits for date of
service, site of service, or diagnosis codes but we
recommend:
– Date of service – day on which 20-minute requirement is satisfied
– Site of Service – billing practitioner’s primary practice location
– Diagnosis codes – list at least 2 of beneficiary’s chronic conditions
 CMS has not advised on when to submit claim,
but we recommend any time after 20-minute
requirement is satisfied for given month

47. 47
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.”

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49. 49

50. 50
21st Century Cures Initiative
• House Energy & Commerce Committee 2014/2015
• Led by Chairman Upton (R-MI), Rep. DeGette (D-CA)
• “. . . the discovery of clues in basic science, to
streamlining the drug and device development
process, to unleashing the power of digital medicine
and social media at the treatment delivery phase.”
– Waive arduous 1834(m) restrictions
– Contemplating the inclusion of remote patient monitoring
• 4 DC roundtables, 8 hearings, 15 local roundtables and
5 whitepapers

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SGR Fix Legislation
• CCM not conditioned on AWV or IPPE
• RPM listed as “clinical practice improvement
activity” under new Medicare value-based
purchasing program
– Merit-Based Incentive Payment System (MIPS)
• Study on RPM benefits and barriers to adoption

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MU3 Proposed Rule

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Coordination of Care Through
Patient Engagement
• Proposed Measure 3: Patient-generated health data
or data from a non-clinical setting is incorporated
into the certified EHR technology for more than 15%
of all unique patients….

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Robert Jarrin
Senior Director, Government Affairs
Qualcomm Incorporated
1730 Pennsylvania Avenue, NW
Suite 850
Washington, DC 20006
rjarrin@qualcomm.com
Martie Ross
Principal
Pershing Yoakley & Associates, PC
9900 West 109th Street
Suite 130
Overland Park, KS 66210
mross@pyapc.com