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New year, new code: How to get paid for chronic care management in 2015, part 3
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Beginning in 2015, physicians and other qualified health care professionals will be able to separately bill Medicare for providing non-face-to-face chronic care management, or CCM, services by billing CPT code 99490. In recognizing and payment for these non-face-to-face services, the Centers for Medicare and Medicaid Services has taken an important step toward recognizing that care coordination is an essential feature of providing high-quality primary care and that important aspects of this care occur when the patient is not in the office.
Catherine A.
Brandon
We described the scope of service in part 1 and health information technology requirements in part 2; however, several unanswered questions and challenges regarding the use of this new code remain. Unfortunately, CMS currently does not plan on providing any additional clarity on these issues. To the contrary, CMS staff have recently stated that they learned some lessons from the poor utilization of the transitions of care management codes (99495 and 99496), so they intentionally placed very few requirements on — and thus, provided very little guidance to — practices to facilitate widespread use of the CCM code.
For instance, beneficiaries are eligible to receive CCM services when they have two or more chronic conditions that place them at significant risk of death, acute exacerbation/decompensation or functional decline. CMS, however, has not issued guidance interpreting these criteria, defined “chronic condition” or provided a list of conditions that qualify. CMS has not provided clarity on, for instance, whether there are any complexity requirements for the two chronic conditions or the level of risk of exacerbation or functional decline required to support the medical necessity of the service. Due to the lack of clarity as to patient eligibility, practices will need to decide if and how they wish to determine and document patient eligibility. Making and documenting such determinations could also support the medical necessity of the CCM service. So, how should practices determine patient eligibility? Practices could use published algorithms or standards, develop internal standards or make case-by-case determinations (aka, the “know it when you see it” standard) supported by chart documentation.
Paul Rudolf
Similarly, CMS has provided general information regarding the required scope of services, but it has not provided specific guidance as to how to properly comply with those requirements. For instance, providers must inform eligible patients about the availability of CCM services, but CMS has not specified what information must be provided or how that information must be presented (eg, in writing). The code allows clinical staff under direct supervision to provide CCM services but does not elaborate on whether there are minimum qualifications for staff to provide such services. Moreover, CMS has provided very little guidance regarding the level of documentation required to bill the code. For example, would the medical record need to account for exactly how the 20 minutes per month was spent?
When asked about the lack of specificity around these code requirements at a recent meeting of physician specialty societies hosted by the American Medical Association, CMS said that it intended to provide practices with flexibility in providing CCM services and indicated that it did not plan on providing additional guidance. While giving providers some leeway in tailoring CCM services to their patients and their practice, this flexibility also creates compliance risks. Practices currently have no way of knowing how CMS will audit use of the code or what criteria will be used to identify overpayments. Without additional clarity, practices would be advised to err on the side of over-documentation, which can be time consuming and labor intensive.
Finally, practices will need to develop policies on how to address refusals to consent to CCM services by eligible beneficiaries. Some eligible beneficiaries may not want to pay the 20% copayment, which could be as high as $100 per year, especially if they feel that these services used to be provided for free. Refusals may put practices in a difficult position. If practices were already providing CCM services to patients, do they stop providing those services to patients who refuse? Do practices decline to treat patients entirely if they refuse to receive CCM? Do practices continue to provide CCM services free of charge to those who refuse, raising questions of equity for those patients who have agreed to receive and pay for CCM services? Practices should carefully think through these questions and develop a clear and consistent policy as they begin to educate their patients about this new service.
Catherine A. Brandon is a special assistant for Oversight, Office of the Assistant Secretary for Legislation.
Paul Rudolf is a partner in the Arnold & Porter LLP's FDA and Healthcare practice group. He can be reached at Paul.Rudolf@aporter.com.