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New year, new code: Things to remember when billing for CCM
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Beginning this year, 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 paying for these non-face-to-face services, CMS 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. We have described the scope of service in Part I and health information technology requirements in Part II. In Part III we discussed uncertainties surrounding patient eligibility, scope of services and patient consent. This article addresses implementation issues that physicians should keep in mind as they develop their capabilities to bill for CCM, particularly if they consider using third-party contract employees to provide CCM services.
Paul Rudolf
General supervision required
Billable CCM services may be provided by clinical staff, incident to the services of a physician or mid-level practitioner, under general supervision. Under Chapter 15, Section 60.1 of the Medicare Benefit Policy Manual, incident to services are ones that are “furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.” Most incident to services must be provided under direct supervision of the physician. That is, the physician must be present in the office while the “incident to” services are furnished. However, only general supervision of clinical staff personnel by the supervising physician is required to bill for CCM. That is, the physician need not be present in the office at the time the “incident to” service is furnished. This is because CMS recognized that CCM services are provided when the supervising physician may be making rounds, after hours or on weekends when direct supervision would not be possible.
It is unclear how much supervision will satisfy the general supervision requirement because CMS has not defined what activities count toward satisfying the “general supervision” requirement for CCM services. Although not directly on point, the Medicare manual defines “general supervision” for provision of services to homebound patients to mean that the services are performed under the physician’s overall supervision and control, although the physician need not be physically present at the patient’s place of residence.
Therefore, due to the lack of clarity about what qualifies as general supervision, physicians should set up internal policies for supervision of clinical staff providing CCM services. Internal policies may include requirements related to how often, for each patient, the physician should meet with the clinical staff, how often or when clinical staff should notify the physician that a CCM service was provided, and how often or when the supervising physician should review medical record documentation of CCM activities. Ultimately, the supervising physician must provide sufficient oversight to demonstrate ongoing participation in the patient’s care and that CCM is being delivered as part of the prescribed course of treatment.
Skill level of clinical staff
CCM services must be performed by clinical staff. Medicare policy states that auxiliary staff may provide incident to services. Examples of such auxiliary personnel include licensed professionals such as nurses, technicians and therapists and non-physician practitioners such as physician assistants and nurse practitioners. Beyond these examples, however, CMS does not elaborate on what credentials clinical or auxiliary staff must have to provide CCM services. Nevertheless, physicians must ensure that staff are qualified to provide CCM support. Specialty societies may be able to provide guidance on staff qualifications.
Employment arrangements
Clinical staff need not be direct employees of the practitioner or the practice, and the rule notes that clinical staff may be contract workers. However, CMS does not elaborate on the scope of a contract employment relationship or whether only some, or all, CCM services may be contracted to third-party clinical staff. CMS suggests that there should be a “close relationship” between the practitioner and clinical staff providing the services. In addition to adoption of a supervision policy, suggested above, physicians should identify which CCM services will be contracted to third-party clinical staff and which will be performed by the physician’s employees.
EHR access
Providers billing for CCM must electronically capture care plan information in an EHR or other health IT or health information exchange platform and make the care plan information available on a 24-hours-a-day/7-days-a-week basis “to all practitioners within the practice whose time counts towards the time requirement for the practice to bill the CCM code; and share care plan information electronically (other than by fax) as appropriate with other practitioners and providers.” The language of the final rule, although not entirely clear, appears to provide some discretion to practices in the manner in which contracted clinical staff can access the patient’s EHR and the amount of information they are required to have. Physicians should ensure they have the capability to provide such access. Additionally, providing access to non-employee clinical staff raises HIPAA privacy concerns. The CCM rule requires physicians to document patient authorization for electronic communication of his or her medical information to be shared with other treating providers in the EHR. Physicians should be clear in this disclosure, which should be signed by the patient, that CCM clinical providers may not be part of the physician’s full-time staff. Physicians should also require signed business associate agreements between all third-party clinical staff and the physician or practice.
Documentation requirements
Although there are no specific documentation requirements for proving that 20 minutes or more were spent on CCM services, billing providers should require clinical staff to document their time and describe the CCM service that was performed (ie, coordinating care, communicating with the patient, etc.). This policy should not only apply to clinical staff but to the supervising physician as well. Implementing a documentation and document retention policy for CCM services will protect the provider or practice in the event of an audit.