CMS finalizes payment for chronic care management in 2015

January 30th, 2015 - Betsy Nicoletti

In the 2015 Final Physician Fee Schedule released on Halloween (CMS loves holiday releases of rules) CMS continues to state its support for primary care. One of the methods: a new benefit, chronic care management (CCM) for which they are proposing a rate of about $40 for 20 minutes or more of this non-face-to-face service during a calendar month. We knew about this from the proposed rule but were in wait and see mode until the final rule came out.

Here’s a surprise! CMS is going to use a CPT code instead of developing a HCPCS code to describe the service. In the proposed rule they stated their intention of developing a HCPCS code but they've changed their minds. This means that practices can learn about this code right in a resource that is sitting on their shelves. I hope everyone reading this has their 2015 CPT code on the desk right now.

The new CPT code is 99490: chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following elements:

multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
chronic conditions placed the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
comprehensive Care plan established, implemented, revised, or monitored.

There is an additional editorial note stating “chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately.”

CMS will not use the CPT codes for complex chronic care coordination services 99487—99489. Those will continue to have a bundled status indicator.

In order to be eligible the patient must have two or more significant chronic problems, expected to last at least 12 months or be life long conditions. They must be the type of conditions that pose a real risk to the patient’s health and well-being. The practice must implement a care plan that addresses the patient’s conditions and a clinical staff member must spend 20 minutes during a calendar coordinating care and communicating with the patient. The practice must use a certified EHR. The physician develops a care plan, and everyone who has contact with the patient must have access to the electronic care plan. A copy of the care plan is provided to the patient, electronically or on paper. The electronic record must include a full list of problems and medications and should facilitate caring for the patient during care transitions. Medication reconciliation is required as part of the service. The patient must have access to the practice 24 hours a day, 7 days a week. One provider must be designated for continuity of care. Care management includes assessment of the patient’s medical, functional and psychosocial needs.

The practice must create a patient-centered care plan, manage care transitions, and coordinate with home and community services.

Informed consent is required before starting the service. The practice must inform the patient that they will provide this service and get written consent from the patient to do so and to share information with other providers. The practice must also inform that patient that they can revoke this consent and stop receiving CCM services at any time. Document these communications in the record, and give the patient a written or electronic copy of the care plan. The co-pay and deductible are not waived for this service, but will be patient due.

CMS is proposing general, not direct, supervision of the clinical staff who perform these services. Nursing staff after hours or during normal business hours may perform these coordination services even if the physician or billing NPP is not in the office

It looks like a lot of work to me for $40.00. The practice may only report this service during the month in which the clinical staff has 20 minutes of non-face-to-face time with the patient. If the practice is already providing these services as part of a patient centered medical home, the service will be easier to provide and may not represent significant additional cost. The payment may support the additional infrastructure needed to manage the care of these patients.

If you have your 2015 copy of the CPT book—and, again, I hope you do-- you can read for yourself in more detail what the billing rules are. I am summarizing these but it is no substitute for reading them yourself. First, both CPT and CMS state that clinical staff should be doing the work. Also, a practice may not count any clinical staff time on a day when the physician or qualified healthcare professional (NP/PA) has an evaluation and management service with the patient. However, E/M services may be reported during the same calendar month the chronic care management is provided. There is a list of services in the CPT book that are bundled into chronic care management. These include care plan oversight and transitional care management, amongst other codes. The surgeon may not perform chronic care management during the postop period.

If your practice is already a patient centered medical home or you are already providing case management for a group of chronically ill patients, you are ready to begin performing chronic care management. However, if you are not already providing the services it is unlikely that you will be able to do these starting January 1. It requires an infrastructure within the practice to provide the services. Also, you will need to have an evaluation and management service with the patient to explain the service, sign the informed consent, and develop the care plan. This calls for gradually rolling out chronic care management services not immediately reporting them on all patients who will be eligible. Remember this is not a per member per month benefit-- just because you provide the service one month does not mean you can provide the service the next month. The clinical staff must spend at least 20 minutes providing these coordination and care management services in order to report them. Most practices don't have a template or form setup for this. Groups will need to think about how and where this information is being documented before rushing to bill for this service.

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