Medicare Compliance & Reimbursement

Budget for these 9 factors first.

The Centers for Medicare & Medicaid Services (CMS) debuted a new chronic care management code 99490 a few months ago. But do you know how to report it or under what conditions you might face a denial? Make coding this service easier for your practice with these tips from a webinar organized by the agency.

“We are paying separately in 2015 under the Physician Fee Schedule for 99490 (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…) for face-to-face care management and coordination services,” said Ann Marshall, MSPH, of CMS’s division of practitioner services on the Feb. 18 webinar “Chronic Care Management Services.”

Income opportunity: “The payment amount in the office setting, the national average is approximately $43.00,” and coinsurance applies, she added. Therefore, even if your facility provides CCM services for only 20 patients per month, you’ll see an annual income boost of $10,320.

The scoop: You can bill the code once per calendar month for patients who have two or more chronic conditions, as long as the provider furnishes a minimum of 20 minutes of qualifying care. Just one practitioner can bill the service each month, and you can’t collect for transitional care management or other “overlapping care” management services during the same service period, Marshall said.

No automated edits will exist in the claim system for the date of service or place of service for CCM, Marshall said, but CMS is keeping an eye on that issue and may create directives in the future on that topic. “Please do call your MACs because they may have preferences for the date of service and when you submit,” Marshall said.

Know What the Service Must Include

To report the chronic care management service, you’ll have to meet nine essential criteria or you won’t be able to bill the services, Marshall said. The criteria are as follows.

1. Use of a certified electronic health record (EHR) to record demographics, problems, medications and medication allergies. In addition, you will need to create a structured clinical summary record using your CCM-certified EHR.

2. Continuous 24/7 patient-provider access so the patient always has “means of timely contact with health care providers having access to the health record, to address urgent chronic care needs at all times,” Marshall said. “Most practices already have this requirement in the form of an on-call service,” she added.

3. Continuity of care with a designated member of the care team, “and that includes the ability to obtain successive routine appointments with that individual,” she said.

4. A systematic assessment of health needs and provision of preventive services, which includes ensuring that the patient does not miss any medical, functional or psychosocial assessments, and that patients get all preventive services in a timely manner. “Also key here is medication reconciliation with review of adherence and potential interactions,” Marshall added.

5. Establishment of an electronic care plan, which requires the creation and maintenance of a comprehensive plan of care for all patient-centered health issues. “We do require that a written or electronic copy of the care plan be given to the patient or the caregiver as appropriate, and that you document provision of the care plan in the EHR using the CCM-certified technology,” Marshall added.

No specific format is required for 2015, but you must at least electronically capture the care plan information and make it available on a 24/7 basis to all practitioners in the practice, including those who provide care after-hours, electronically (but not via fax), Marshall added. You must also be able to share the information electronically with other providers and practitioners who see the patient.

6. Manage care transitions between and among health care providers, as well as hospital, nursing facility and ER providers. “There are two pieces of this element: A certified EHR technology requirement to create and format the clinical summary you’d be exchanging with other providers and managing care transitions using CCM certified technology,” Marshall said. “But when you are transmitting or exchanging that summary of care record, we do provide for using any electronic tool other than fax, at least for calendar year 2015.”

What about absence of EHR? A caller to the forum asked what happens if one of the participating providers cannot receive the information electronically, thus precluding the CCM doctor from transmitting the information that way. “Very few providers cannot accept, for example, a HIPAA-compliant encrypted email, which is perhaps a bit surprising, but I know there are some areas of the country where electronic capability and internet is very limited,” Marshall replied. In this case, she recommends using “a HIPAA-compliant encrypted email or workaround that your certified EHR provides; or you can with another provider.”

When the caller pointed out that she works with a provider who only accepts transmissions via mail or fax because transition to an EHR is too costly, Marshall urged her to use an encrypted email.

If the physician can’t accept a HIPAA-compliant email, don’t consider faxing the patient’s information. “You can’t just send a straight fax,” Marshall said, although some certified EHR products have a workaround in which the CCM data is translated into a fax, “so the sender can get a credit for an electronic send but it can end up as a fax in the hands of the receiver, and if you have such a workaround you can certainly take advantage of that,” Marshall said.

Lost income: If a particular physician of the patient cannot receive the patient’s information electronically and your EHR does not have the above workaround allowing you to send electronic information that turns into a fax on the receiver’s end, you unfortunately cannot bill CCM for that month, Marshall said.

7. Coordination of care with home- and community-based clinical service providers, including communication to and from these providers, and documenting the coordination in the EHR using CCM certified technology.

8. Enhanced communication opportunities for patient and caregivers, including discussing the patient’s care via telephone, secure messaging, secure internet or other non-face-to-face consultation methods that are HIPAA-compliant.

9. Documentation of the patient’s written consent and authorization in the EHR using CCM certified technology, to ensure that the patient understands his eligibility for CCM and that you have the patient’s written informed consent to electronically share protected health information with other providers. This also informs the patient that only one practitioner can furnish and be paid by Medicare for CCM within a given month.

“However, you do need to only obtain informed consent once before furnishing the service, unless the patient chooses to have another practice furnish the CCM service, and in that case the new practice must obtain informed consent prior to furnishing the service,” Marshall said. You don’t need to obtain informed consent annually, she confirmed.

Part of the consent lets the beneficiary know that you’ll be sharing their information with other practices, and therefore, the patient does not need to give additional informed consent documents to the physicians with whom you’ll be sharing the information, Marshall said. HIPAA rules apply to the information sharing, which should help give patients confidence about the practitioners with whom you’ll be sharing the data, she added.