Medicare Fee-for-Service Update: Chronic Care Management

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.