Physician Chronic Care Management – CMS’s Pay for Performance Carrot

March 2nd, 2015 by Rod Baird

Physician[i] Chronic Care Management – CMS’s Pay for Performance Carrot.  Does it apply to LTPAC Medicine and what are the requirements?

CCM is a monthly payment to physicians who enroll their patients in an ongoing ‘shared care’ model.  It’s a bold attempt to build a hybrid model of care that bridges fee-for-service medicine and the PPACA’s population management model.  This blog discusses the potential for using CCM in LTPAC Medical Practices.

As a patient, I want physicians providing the leadership in care delivery.  However – thirty-five years of healthcare management convinces me that Fee-for-Service Medicine creates incentives[ii] that dull the effectiveness of that leadership role.  The Affordable Care Act was a bold attempt to transform our system into one based on population management; it fell short of that goal.

This year, via the 2015 Physician Fee Schedule, CMS adopted a new care model that shoe-horn’s longitudinal population management into the FFS model of care delivery.  It is Chronic Care Management, or CCM, and is embodied in CPT Code 99490[iii].  This is a $40+ monthly payment to an individual medical professional who established a written agreement with a qualified Medicare Beneficiary to provide CCM services.  The CPT definition:

CPT 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: 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.

The complex evolution of Care Management payments in general, and CCM specifically, is beyond the scope of a thousand word blog;  suffice it to say – CCM is here.  How does it work?

On Feb. 18th CMS conducted its 1st online educational program on CCM – Payment of Chronic Care Management Services under CY 2015 Medicare PFS.  For the time being, this is the best insight we’ll get into their thinking.  Here’s what we know is required:

1.Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record, using a complete certified Ambulatory EHR.

2.24/7 access to care management services (requires access to the EHR by a health provider).

3. Continuity of care with a designated member of the care team (probably the same provider who submits the monthly claim).

4. Systematic assessment of health needs and receipt of preventive services. (The assessment can be performed by other clinical members of the team outside of periodic face to face encounters).

5. Electronic care plan (not required to be part of the certified EHR in 2015). Creation/maintenance of comprehensive plan of care for all health issues that is patient-centered, based on a physical, mental, cognitive, psychosocial, functional and environmental assessment or reassessment, etc. Patient/Family receives either a paper or electronic copy of the PoC.

6. Management of care transitions (Summary of Care documents from EHR – delivered electronically at each care transition – e.g. consults, E/D visits, hospitalizations, etc.)

7. Coordination with home and community-based clinical service providers as appropriate (e.g. LTPAC facility staff).

8. Enhanced communication opportunities for patient/family and caregiver (telephone, secure email or web portal, etc.).

9. Informed consent. Individual, or responsible party, executes consent which is stored in the EHR. Multiple specific requirements for compliance. An Annual Wellness Visit, or Comprehensive E&M visit, by the billing practitioner is a prerequisite. Must acknowledge 20% copay on CCM.

10. Documentation of 20 minutes of monthly care management in the EHR by a ‘qualified clinical staff members’ as defined in the 2015 PFS.

IS CCM a Covered Part B service in LTPAC Settings?

CMS published its first draft of the CCM benefit for public comment in the 2014 Physicians Fee Schedule.  That version stated that CCM did not apply to the Nursing Facility Setting.  That was consistent with the AMA’s guidance.  The AMA CPT Manual is a guide, not official CMS policy. The 2015 Physician Fee Schedule completely reworked the CCM definition; it did not contain the Nursing Facility prohibition.  During the CMS provider education call (referenced above) there was a discussion of Place of Service and CCM.  The CMS subject matter experts stated that there was no CMS guidance – this was a decision left to the regional MAC.  That means that there is no single national policy – it is imperative that each medical group, or their state organization, begin a dialogue with their MAC Medical Director. Any guidance should be written.

At this point, ignoring any questions of practicality, it seems possible that the CCM service is covered in all LTPAC settings.  This guidance does seem to duplicate services in the Medicare SNF benefit (POS 31) which requires care coordination at the facility level as a condition of participation.  Further, the assumption (hope) is that individuals in a SNF stay are likely to return to the community.  In the best of worlds, any individual likely to experience a SNF episode of care would be receiving CCM services from a community based PCP; that is consistent with arguments AMDA and the SHM[iv] are making about eliminating POS 31 for ACO and VBP attribution.  We suggest LTPAC medical groups refrain from attempting to bill for CCM of short-stay PAC patients.

I believe CCM should apply to the nursing  facility POS 32); care in this setting is either privately purchased by the individual, or covered by skimpy State Medicaid payments.  Neither of those payment sources should prohibit individuals purchasing Medicare Part B or C coverage from accessing this covered service.  That point of view is echoed by the AAFP[v].

There was never doubt that CCM applies to individuals in the Assisted Living/Rest Home, or Home setting. However, if the individual is receiving home health services, the physician reporting CCM service is prohibited from receiving payments under G0181 (supervision of individual receiving home health services – 30 minutes) during the same month.

CCM care is inherently ‘Office Based’ – time spent inside the facility is properly associated with the face to face E&M encounter.  Based on that logic, the billing location is POS 11 – Office.  That is already the CMS approved protocol for billing Home Health Care Plan Certification/Recertification (G0180/G0179).

Because the original work on CCM arose in the Ambulatory setting, many of the specifications will require significant thought to compliantly blend them into the NF/ALF/HHA setting.  There is nothing insurmountable, but it is requisite that the institution’s staff be electronically integrated with much of the patient’s EHR and/or Electronic Care Plan.

A caveat – in the past few months a cottage industry for ‘out-sourced’ CCM services arose.  We’ve received multiple proposals for a turn-key CCM service.  The pitch almost always includes an invitation to estimate the number of patients with 2+ chronic conditions served by the practice.  Plug-in that number and it is multiplied by $40/month by 12 months.  The numbers are impressive – in LTPAC Medicine they are often approaching $500K.  Today’s signal from CMS is that most claims will be paid if approved by the MAC.  What is unsaid is the significant potential for retrospective payment audits.  Said another way – two chronic diseases alone do not create ‘medical necessity’. Make sure that your prospective venture partner is going to be around if a payback arises.

We believe that CCM is a significant opportunity for most LTPAC Medical Practices to receive payments for a critical service – one that can pay for the Management in Care Management.  At the same time, we recommend practices view these payments as a tool to document the extensive clinical information required to:

  • Create meaningful patient/family engagement
  • Support electronic LTPAC Medication Management
  • avoid (re)hospitalization, and
  • report on PQRS/VBP, MU, and ACO value sets

In our roles as LTPAC Practice Managers and EHR developers, we’ll be building the tool kits needed to implement a value driven CCM strategy.  You are invited to join the discussion.  We’ll be at Booth #400 at AMDA 2015 in Louisville, and other leading conferences throughout the year.

  1. Throughout this discussion, the word Physician additionally refers to Nurse Practitioners, Clinical Nurse Specialists, Certified Nurse Midwives, and Physicians Assistants.
  2. Documented shortcomings include; duplicate testing, treatment selection based on reimbursement policies, etc.
  3. Current Procedural Terminology (CPT) – a registered trademark of the American Medical Association.
  4. The  Society of Hospital Medicine
  5. American Academy of Family Practice


Rod Baird

About Rod Baird

Rod Baird is the Founder and President of Geriatric Practice Management (GPM). Since 1977, he’s led provider and management organizations that deliver care to Medicare/Medicaid beneficiaries. Past programs he’s overseen include home health, personal care, hospice, rehabilitation hospitals, adult and psych daycare, alcohol/drug rehabilitation, industrial medicine and primary care practices. The Centers for Medicare and Medicaid Services (CMS) selected Baird as one of only 73 individuals to serve with its InnovationProgram. His educational background includes a Master’s Degree in Physical Chemistry from the American University, Washington, D.C.

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