CMS’ new chronic care management (CCM) code program launches Jan. 1, 2015, but there is some confusion around the requirements of the program since it was just finalized in November. To help alleviate some of that confusion, here is a Q&A on the program:

Since patients are required to pay a co-pay under this program, won’t that dissuade most from participating?

Only one in 10 beneficiaries relies solely on the Medicare program for health care coverage. The rest have some form of supplemental coverage to help with medical expenses, so 90% of your patients may not have to pay out of pocket for the co-pays.

Is there a list of chronic conditions that qualify under the program?
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CMS maintains a Chronic Condition Warehouse (CCW) that includes information on 22 specified chronic conditions. However, the CCW list is not an exclusive list of chronic conditions; CMS may recognize other conditions for purposes of providing CCM.

What is the reimbursement amount for CCM?

Multiple figures have been bandied about. In the final rule issued in November, CMS set the final number at $42.60

Will Medicare Advantage (MA) plans reimburse for CCM? What about commercial payers?

A Medicare Advantage plan is required to offer its enrollees at least traditional Medicare benefits, which now will include CCM. It seems reasonable to assume that an MA plan will pay for CCM just as it now pays for other physician services. Whether commercial payers will pay for CCM remains to be seen, although the fact that CMS is paying for this service makes it more likely.

Which providers can bill Medicare for CCM?

Providers eligible to bill Medicare for chronic care management include:

  • Physicians (regardless of specialty),
  • Advanced practice registered nurses,
  • Physician assistants,
  • Clinical nurse specialists, and
  • Certified nurse midwives (or the provider to which such individual has reassigned his/her billing rights)

Other non-physician practitioners and limited-license practitioners (e.g., clinical psychologists, social workers) are not eligible.

Is a practice required to be recognized as a patient-centered medical home (PCMH) to provide CCM?

CMS had proposed patient-centered medical home (PCMH) recognition as a condition for billing under chronic care management coding, but the Final Rule does not include that requirement. However, the transformation to PCMH should position a practice to successfully provide CCM. Also, many commercial payers offer financial incentives for PCMH-recognized practices.

Are there services a provider must furnish to a beneficiary prior to billing for CCM for that beneficiary?

While CMS strongly recommends that a provider furnish an annual wellness visit (HCPCS G0438, G0439) or an initial preventive physical exam (G0402) to the beneficiary, there are no prerequisite services to bill for CCM.

Can a provider bill for other services during the same month as CCM?

If a provider furnishing CCM performs any other services for the beneficiary (such as an office visit or an immunization), the provider should bill for that service in addition to CCM.

Are there services for which a provider is not allowed to bill during the same calendar month as CCM?

Yes, there are four:

  • Transitional care management (CPT 99495 and 99496)
  • Home healthcare supervision (HCPCS G0181)
  • Hospice care supervision (HCPCS G0182)
  • Certain end-stage renal disease (ESRD) services (CPT 90951- 90970)

How does a beneficiary revoke consent?

CMS hasn’t specified a particular method for patients to revoke consent under the chronic care management program, but to help avoid confusion, providers should specify on their CCM consent form the manner in which the patient should revoke consent (for example, delivered in writing to the provider). That revocation requirement may or may not be recognized by CMS, however; CMS may deny payment even though the beneficiary’s revocation is provided in a manner other than that specified on the provider’s consent form.

IS EHR software required to bill for the new chronic care management code?

Yes; originally, CMS was going to require use of a 2014 certified EHR (as MediTouch is), but softened their approach and is allowing 2011 certified EHRs as well. In addition, it will be extremely difficult to track and manage the agreements, care and billing time frames without EHR software designed to do so.

Want to learn more about how to get paid for the new chronic care management code?

You can, in a free on demand webinar: How to Get Paid for the New Chronic Care Management Code, with Dr. Seth Flam.

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