Home Health & Hospice Week

20 eligible patients could earn your docs up to $10,000 annually.

Physicians referring complex patients your way may be entitled to more Medicare payment for them, and not even know it.

The Centers for Medicare & Medicaid Services decided to reimburse non face-to-face care management services for the chronically ill starting in 2015 — a service many medical groups have been offering unreimbursed for years.

“Historically, CMS had taken the position that payment for non-face-to-face care management services ... is incorporated into the payment for face-to-face evaluation and management services,” says Krista Teske, senior analyst at The Advisory Board Company. “However, remote care management does take substantial time and energy — energy that might otherwise be put into additional office-based care.”

Now, docs no longer have to make difficult financial decisions to provide clinically valid chronic care management (CCM) services.

“There is also the potential for enhanced, systematic care of patients’ chronic conditions that may lead to benefits such as improved outcomes, less expensive care globally (e.g., by avoiding hospitalizations and trips to the ER), etc.,” says Kent Moore with the American Academy of Family Physicians.

Educate Docs On Their CCM Coding

Another perk: Even patients may benefit financially, Moore points out. “The Medicare coinsurance and deductible associated with a hospital admission is likely to far outweigh the $8-$9 coinsurance for a month’s worth of chronic care management,” he says.

Educate docs: These good reimbursement tidings don’t come without strict parameters for getting paid. For example, “Medicare is only recognizing CPT® code 99490 for billing these services,” Moore notes, even though CPT® has two other codes (99487 and 99489) for CCM services. “If a practice bills Medicare for 99487/99489 rather than 99490, they will not get paid,” Moore says.

The code descriptor for 99490 itself is jam-packed with criteria that need to be met. “Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

• 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.”

Critical: “The code can only be billed every 30 days by one provider,” stresses Seth Flam, DO, CEO and president of HealthFusion.

Docs who overbill could easily invite an audit, Flam explains, and in any CMS audit, the provider would need to prove they have patient permission to bill the code, as well as documentation for the 20 minutes of non-face-to-face work performed during the 30-day billing period. “If a provider does not have software designed to track these metrics, we advise that they carefully document and then keep and store accurate records related to this service,” he adds.

While neither CMS nor CPT® list specific chronic conditions required for reimbursement, 99490 spells out exactly what defines a “chronic care” patient. This code also requires an active, comprehensive care plan.

Reimbursement requirements don’t stop at the code description, as dense as it is. The 2015 Medicare Physician Fee Schedule final rule also lists scope of service must-haves before your referral sources can bill 99490. CMS did not make new requirements for CCM services, but, rather, re-emphasized the existing scope of services criteria spelled out in the prior year’s fee schedule rule (see related story, this page).

“Optimizing reimbursement will likely in-volve optimizing identification of eligible patients, securing their agreement to bill for the service, and then tracking the chronic care management provided on behalf of those patients, and claiming payment each month that the 20 minute threshold for clinical staff time is met,” Moore says.

Initially physicians must ensure their practices meet all the requirements described by CMS, Moore says, “but you may also need to develop a checklist of the requirements pertinent to a particular patient (e.g., Did the patient receive a copy of his or her care plan?)”

Important: Some physicians may not be used to developing and maintaining the patient’s care plan, Teske notes. “In order to bill for this code, providers and their IT systems will have to increase their sophistication in handling care management.”

Don’t miss: Physicians should track and document the clinical staff time spent to ensure that the 20-minute threshold is met in case their practice is ever audited by Medicare, Moore says.

The payoff: If your referral sources get their ducks in a row, the income from CCM services could be a nice booster. The Medicare allowance for CCM services was calculated at $42.60 in the 2015 final rule. Even if a physician practice provides CCM services for only 20 patients per month, it will see an annual income boost of $10,224.

Your docs must obtain written patient consent each year to furnish CCM services. First, it’s a requirement to get paid, and second, patients need to know what they owe.

“Getting consent may be initially difficult because patients will incur a 20-percent copayment for receiving these services, or roughly $8 monthly, and this amount may be prohibitive for beneficiaries,” Teske says. “In addition, many patients may be infuriated that they are now being charged for services that they didn’t know they were receiving previously or that they are used to getting for free.”

Think ahead: “Providers should be prepared to ‘sell’ the virtue of these services to pa-tients,” Teske says, “otherwise, they risk being unrecognized for services that they will likely provide whether or not they are able to bill for them.”

Your referring physicians can always remind their patients they can opt-out of receiving CCM services at any time. 

Note: Read more in CMS’s final rule — scroll to page 442 at http://tinyurl.com/q6yx46r.