Chronic Care Management (CCM) Services. Presented by Noridian Part B Medicare Provider Outreach and Education December 2015

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1 Chronic Care Management (CCM) Services Presented by Noridian Part B Medicare Provider Outreach and Education December 2015

2 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC (Noridian). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

3 ACRONYM AWV CFR EHR E/M HIPAA IOM MLN MPFS DESCRIPTION Annual Wellness Visit Code of Federal Regulations Electronic Health Records Evaluation and Management Healthcare Insurance Portability and Accountability Act Internet Only Manual Medicare Learning Network Medicare Physician Fee Schedule December

4 Agenda Chronic Care Management (CCM) Overview Eligible Beneficiaries Eligible Providers Scope of Service Billing Noteworthy Q&As Resources December

5 Objective To give providers tools and information about the Chronic Care Management (CCM) program, how to bill and document appropriately December

6 Chronic Care Management (CCM) Overview December

7 Overview Chronic Care Management Effective January 1, 2015 Critical components of primary care Contributes to better patient health and care Reducing Medicare spending Reimburses eligible providers for non face-toface care coordination services December

8 CCM Basics Furnished to patients with multiple chronic conditions Need signed patient s prior written permission Form created by provider Retroactive consent not allowed Expected to last at least 12 months or until patient death Comprehensive care plan established, revised, implemented and monitored December

9 CCM Basics2 Team scope of service extensive 24/7 patient access to physician/staff services Access to electronic patient records, plan of care revision, medical, functional and psychosocial needs Communicate with other treating professionals Includes time spent by clinical staff Without direct physician supervision General supervision if incident to met December

10 Comprehensive Care Plan Medication management Community/social services ordered Agency specialists/services (outside the practice) who will direct/coordinate Expected prognosis Measureable symptom management with planned interventions Schedule periodic review and care plan revision December

11 Eligible Beneficiaries December

12 Eligible Population Beneficiaries with multiple (two or more) chronic conditions Expected to last at least 12 months or until patient death Beneficiary at Significant risk of death Acute exacerbation Decompensation Functional decline May include approximately 2/3 of all Medicare beneficiaries to be covered December

13 Chronic Conditions* Alzheimer s disease and related dementia Arthritis Asthma Atrial fibrillation Autism spectrum disorders Cancer Chronic Obstructive Pulmonary Disease December

14 Chronic Conditions*2 Depression Diabetes Heart Failure High Cholesterol Hypertension Ischemic Heart Disease Osteoporosis *Not all inclusive list December

15 Beneficiary Access to Provider Team 24/7 access to care management services On call availability In compliance with HIPAA, using secure internet, messaging, telephone, etc. Continuity of care with a designated member of the care team Able to obtain routine appointment December

16 Eligible Providers December

17 Practitioners Eligible Physicians Certified Nurse Midwives Clinical Nurse Specialists Nurse Practitioners Physician Assistants December

18 Clinical Staff Eligible Eligible to contribute their time to the monthly CCM documentation Medical Assistants Nurses Pharmacists Technicians Therapists December

19 Practitioners Not Eligible Cannot bill, but may refer/consult Clinical Psychologist Dentist Podiatrist Their time counts toward monthly service Non clinical staff time does not count Billers Other administrative staff December

20 Supervision Exception under incident to rule Clinical staff under general supervision Overall direction without physician presence Rather than direct supervision Where physician must be in the clinic/office December

21 Scope of Service December

22 Scope of Service Provider needs beneficiary prior informed consent obtained only once Unless patient changes eligible practitioner Create form-written informed consent or decline Let patient know Only one practitioner can furnish and bill Right to discontinue CCM verbally or in writing Cost sharing applies Coinsurance and deductible December

23 Scope of Service2 Structured recording of demographics, problems, medications, medication allergies and the creation of a structured clinical summary record, using a certified EHR Certified EHR technology December

24 Scope of Service3 Systematic assessment of health needs and receipt of preventive services Assessment of medical, functional and psychosocial needs Approach to ensure receipt of recommended preventive services Medication reconciliation Oversight of management of medication December

25 Scope of Service4 Electronic care plan Create/maintain comprehensive plan of care Electronically capture plan of care Available 24/7 to practitioners within the practice Whose time counts towards requirement Exchange care plan summary electronically (other than by fax) with other practitioners Written/electronic copy to patient/caregiver, documenting EHR provision for CCM December

26 EHR and Other Electronic Technology Requirements Certified EHR technology Version acceptable under EHR Incentive Program December 31 st of each year preceding Medicare payment year Guidance/Legislation/EHRIncentivePrograms Calendar year 2015 May use EHR technology certified to 2011 or 2014 editions of certification criteria December

27 Comprehensive Care Plan Problem list Expected outcome and prognosis Measurable treatment goals Symptom management Planned interventions and identification of individuals responsible for each intervention December

28 Care Management Service Systemic assessment Patient s medical/functional/psychosocial needs System based approaches ensuring receipt All recommended preventive care services Medication reconciliation with review Adherence and potential interactions Oversight of patient Medication self management December

29 Managing Care Transitions Between health care providers and settings Include referrals to other providers Providing follow-up after an emergency department visit and after discharges from hospitals, skilled nursing facilities or other health care facilities December

30 Other Coordination Opportunities Coordination with home and communitybased clinical service providers as appropriate Communication to and from these providers Methods are subject to HIPAA Enhance communication opportunities for patient and caregivers December

31 Billing December

32 CCM Billing Only one practitioner bills/allowed monthly Non F2F services Reimburse approx. $40 monthly Place of Service (POS) = 11 (Office) 20 minutes or more; per 30 calendar days Aggregated/documented by different clinicians Deductible/Coinsurance apply Before CCM, provider billing must furnish AWV or comprehensive E/M December

33 Other CCM Not Covered B (bundled) not separately covered 99487/99489 Complex Chronic Care Management 99090/99091 Remote patient monitoring or analysis of patient-generated health data As long as not the only work performed, may count towards minimum 20 minutes December

34 Other Monthly Services Medicare does not make duplicate payment for similar services Do not bill same month as Transitional Care Management (TCM) End Stage Renal Disease (ESRD) Home Health/Hospice Care G0181-G0182 December

35 Payment Information Payment for CCM service Separate under Medicare fee schedule Medicare Physician Fee Schedule (PFS) Look Up tool December

36 Noteworthy Q&As December

37 Q & A What date of service should be used on the physician claim and when should the claim be submitted? The service period for CPT is one calendar month and CMS expects the billing practitioner to continue furnishing services during a given month as applicable after the time threshold is met. When the 20 minute threshold to bill is met, the practitioner may choose that date of service and not hold the claim until the end of the month. December

38 Q & A2 Can CCM services be subcontracted out to a case management company? What if the clinical staff are located outside of the United States? A billing physician (or other appropriate practitioner) may arrange to have CCM services provided by clinical staff external to the practice (e.g. case management company) if all the "incident to, state scope of license and other rules for billing CCM are met. Note: There is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9), CCM services cannot be billed if provided to patients located outside of the U.S. December

39 Resources December

40 Medicare Learning Network (MLN) Official CMS for Medicare FFS Providers Products available: Web-based Training Brochures Fact Sheets Quick Reference Charts Most products come in downloadable/hardcopy formats MLN products FREE of charge and shipping MLN dedicated web pages: MLN General Information -- MLN Articles -- MLN Products -- MLN Web Guides -- December

41 CMS Booklet Current May pages https://www.cms.gov/ Outreach-and- Education/Medicare- Learning-Network- MLN/MLNProducts/D ownloads/chroniccar emanagement.pdf December

42 Other CMS Resources December

43 CMS Resources ICD-10 Questions? https://www.cms.gov/medicare/coding/icd10/ index.html Small practice providers no-cost tool Noridian Resources JE https://med.noridianmedicare.com/web/jeb/topics/ icd-10 JF https://med.noridianmedicare.com/web/jfb/topics/ icd-10 December

44 Reminder: Noridian Not Coders Providers are responsible for determining correct diagnostic/procedural coding to Medicare Noridian Customer Service Representatives (CSRs) shall not make provider determinations about proper use of codes Please refer to other entities for coding sets CPT and HCPCS manuals AMA or specialty association websites American Academy of Professional Coders (AAPC) December

45 Continuing Education Unit (CEU) Attend entire workshop to earn CEU(s) Prefer individual registrations Take short polling survey Pops up after closing out of webinar CEU ed 3 days after presentation Earn 1.0 CEU today No password/index number needed for AAPC PDF presentation ed again with CEU Q/A posted after 30 business days December

46 Questions? Thank you!

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