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New year, new code: How to get paid for chronic care management in 2015, part 2

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From international law firm Arnold & Porter LLP comes a timely column that provides views on current regulatory and legislative topics that weigh on the minds of today’s physicians and health care executives.

Catherine A. Brandon

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 addition to the scope of service requirements described in part 1 of this article, the Centers for Medicare and Medicaid Services has mandated the use of certain electronic health record and other electronic data sharing capabilities in providing CCM services. These requirements attempt to balance the care coordination benefits of health information technology tools with the potential burdens associated with requiring specific technology that may not be widely used while acknowledging existing limitations on interoperability. Whether CMS has stuck the right balance has yet to be seen. If a practice intends to bill for CCM services, it should make sure it has the compliant systems in place to support the activities described below.

Providers billing for CCM must electronically capture care plan information in an EHR or other health IT or health information exchange platform and make this information available on a 24-hours-a-day/7-days-a-week basis to all practitioners within the practice who are furnishing CCM services. CMS does not stipulate what type of technology must be used (eg, the care plan does not been to be created or maintained using EHR technology that is certified to meet particular criteria, such as the EHR Incentive Program). The practice must share care plan information, as appropriate, with other practitioners and providers outside of the practice who are furnishing care to the beneficiary, using any electronic means (other than fax). Similarly, to support transitions of care, the CCM provider must provide relevant patient information through electronic exchange of a summary of care record, using any electronic means (other than fax). All electronic sharing of information must be HIPAA compliant.

CMS also requires practices billing 99490 to use, at a minimum, the edition of certification criteria that is acceptable for the EHR Incentive Programs on Dec. 31 of the prior year. For instance, for CCM payment in CY 2015, a practice could use EHR technology that was acceptable for the 2014 EHR Incentive Program, which included EHR technology that was certified to either the 2011 or 2014 edition. It is important to note that a practice does not need to participate in the EHR Incentive Programs or satisfy the meaningful use criteria established by those programs in order to bill for CCM.

Paul Rudolf

CMS does requires a practice billing CCM services to use certified EHR technology for a number of additional scope of service elements required to bill the code:

• The practice must create a structured recording of demographics, problems, medications and medication allergies. This information must inform the care plan (although as discussed above, the care plan itself does not need to be created or transmitted using a certified EHR), care coordination and ongoing clinical care.
• The practice must create a structured clinical summary record that is formatted according to, at a minimum, the standard for the EHR Incentive Program requirements from the previous calendar year. While, the clinical summary must be structured consistent with these requirements, as noted above, it does not need to be transmitted using a certified EHR when the practice is supporting a patient’s transition of care from one treatment setting to another.
• The practice must document in the patient’s medical record using the certified EHR.
• The patient’s written consent an authorization for CCM services. The practice must also document that all of the CCM services were explained and offered, and note the patient’s decision to accept or decline these services.
• That a written or electronic copy of the care plan was provided to the patient.
• Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and function deficits.

Unfortunately, at a recent meeting with physician specialty societies, CMS said that it is not planning on providing additional guidance on these health IT requirements outside what is described in the Medicare Physician Fee Schedule final rule. CMS also has indicated that, in future years, the EHR requirements may become more stringent as health IT interoperability advances, so practices should look next fall for changes in the scope of services for CY 2016.

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.