In the 2015 Medicare
Physician Fee Schedule Final Rule, CMS approved Chronic Care Management.
This is not a capitated service, or automatically payable for any patient
with 2 or more chronic conditions that are likely to decompensate and
cause hospitalization or death in the next 12 calendar months.
As mentioned, these are
not automatic or capitated payments, and there are 5 important capabilities a
provider must have in order to bill for these services. In addition, they must have authorization from the beneficiary to communicate
electronically with other providers to coordinate this care. The beneficiary must be informed they can revoke this authorization at any time.
The five capabilities
include: (1) Use a certified EHR for specified purposes in the rule;
(2) Maintain an
electronic care plan and provide 24/7 access to it (3) Ensure beneficiary
access to care; (4) Facilitate transitions of care; and (5) Coordinate care.
When a provider submits
a claim for CCM, the provider is attesting to the fact the provider has met
each of these capabilities in full, and there are many provisions to fulfill
for each one.
Importantly, only one
physician can bill for these services in a calendar month. While there is no
speciality requirement, CMS seems to think that the PCP will be the one billing
for the CCM. So, what qualifies a beneficiary for this service?
Those qualifications are
laid out in CPT code 99487:
Complex chronic care
management services, 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;
• Establishment or
substantial revision of a comprehensive care plan;
• Moderate or high
complexity medical decision making;
• 60 minutes of clinical
staff time directed by a physician or other qualified health care professional,
per calendar month
No physician or physician
extender (NP, PA, CNS) should bill for Chronic Care Management without
reviewing the 14 or so pages dedicated to it in the 2015 Medicare Physician Fee
Schedule Final
Rule. If you don’t want to do that,
you’ll need to wait for the billing instructions from your Medicare
Administrative Contractor to ensure you’re following all the rules.
While the code itself
speaks about “staff time” it also speaks about complex medical decision making—physician
staff cannot perform any portion of it that requires medical decision making—this
is reserved for clinicians who can make a diagnosis. So, this is not merely a staff activity. Medicare envisions this as a component to the
overall care of chronically ill patients, and not a replacement to that care.
