Medicare Compliance & Reimbursement

20 eligible patients could earn you up to $10,000 annually … if you follow the criteria to a tee.

Practices and facilities that tag-team to support their most complex patients saw a big victory this fall. The Centers for Medicare & Medicaid Services (CMS) 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 (such as medication reconciliation and coordination across care settings) is incorporated into the payment for face-to-face evaluation and management services,” says Krista Teske, senior analyst of research and insights 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, you no longer have to make difficult financial decisions to provide these 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.,” notes Kent Moore, senior strategist for physician payment for the American Academy of Family Physicians. 

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.

Double-Check Your Coding Criteria

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 needs 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. “For providers that don’t have a software module dedicated to CCM billing, there could be confusion about when the last bill was sent.”

Providers 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.

Ensure Your Scope of Services Measures Up

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 you can bill 99490.

Good to know: 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 chart below for a list summarized from Table 33 in the 2015 MPFS final rule. 

That’s a lot to swallow, but take one step at a time. 

To put it simply, “Optimizing reimbursement will likely involve 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 you must ensure your practice meets all the requirements described by CMS (e.g. 24/7 access to the care team, certified EHR, etc.), 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 providers may not be accustomed to developing and maintaining the patient’s care plan electronically — and many electronic medical systems are not explicitly set up to do, Teske notes. “In order to bill for this code, providers and their IT systems will have to increase their sophistication in handling care management.”

Finally, don’t let this simple detail fall through the cracks: Remember to track and document the clinical staff time spent to ensure that the 20-minute threshold is met in case your practice is ever audited by Medicare, Moore says.

The payoff: If you get your ducks in a row, the income made from CCM services could be a nice booster to your facility. The Medicare allowance for chronic care management services was calculated at $42.60 in the 2015 Physician Fee Schedule final rule. Even if your facility provides CCM services for only 20 patients per month, you’ll see an annual income boost of $10,224.

Get Your Patient in the Know

For more than one reason, you must obtain written patient consent each year in order 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 patients,” Teske says, “otherwise, they risk being unrecognized for services that they will likely provide whether or not they are able to bill for them.” 

If all else fails, remind your patients they can opt-out of receiving CCM services at any time.

To read CMS’ final rule with all the details, scroll to page 442 at this link: http://tinyurl.com/q6yx46r.