Before Chronic Care Management (CCM) was a code, we felt the healthcare system was lacking in care coordination and that someone needed to shed light on the dark spaces (the voids between office visits and transitions in the healthcare system) and help patients make sense of fragmented care. We created CareSync in 2011 to put patients at the center of their care and were already performing chronic care management when CMS announced the code and began reimbursing for it in 2015.
There were stumbling blocks along the way. At first, many Medicare Advantage Plans didn’t acknowledge the code, which was a great disappointment to patients and providers. And we were saddened to see the reimbursement percentage drop in 2016, especially when it was evident the code was working to save dollars and lives.
But then, more and more Medicare Advantage Plans started to embrace the code’s value. And with the recent announcement from CMS about proposed changes to the Physician Fee Schedule (PFS), it’s clear we’re moving in the right direction again.
It appears 2017 will be the next phase of filling the care void. We are proud to have lobbied and continue to lobby for care that puts the patient first and we are very encouraged with the expansion of CCM under the proposed 2017 PFS.
To help you navigate what could be coming next, here is our current assessment of what was relevant in the 856-page proposal in relation to CCM. If we can answer any questions for you, please don’t hesitate to call us at 1-800-587-5227.
Billing Codes and Payment for Services
Currently, payment for CCM services is limited to CPT code 99490, which pays for at least 20 minutes of clinical staff time per month that meets CCM’s requirements. Proposed 2017 changes include the following new codes.
New Codes Used to Initiate CCM Services
GPPP7 is a new add-on code. This would apply one time to expand payment for the billing practitioner who provides extensive face-to-face assessment and care planning during the initiation of CCM services.
New Codes Used to Bill for the Level of Complexity of Continuing Monthly CCM Services
There are two additional codes that recognize the need for reimbursement to allow for the additional time required when providing complex chronic care management services.
The first is CPT code 99487. To bill for CPT 99487, clinical staff must provide at least 60 minutes of complex chronic care management per calendar month.
The second is CPT code 99489. This code reimburses for each additional 30 minutes of clinical staff time per calendar month needed for complex chronic care management. These 30 minute units of time are in addition to the 60 minutes of clinical staff time required for CPT 99487.
Changes to Service Elements Required for CCM Codes
Except for differences in CPT code descriptors, the proposed CCM service elements would remain the same for CPT 99490, 99487, and 99489. All three of these codes would allow for CCM services to be delivered non-face-to-face.
Proposed CCM Codes and Average Reimbursement
CareSync supports these additional CCM billing codes. We believe they are needed to more accurately reflect the time and effort it takes to initiate CCM services and provide coordinated care and care planning for patients.
CPT 99490 increases by 3.5% to $42.22
New CPT 99487 $92.66
New CPT 99489 $46.87
New Add-On Initiation Code GPPP7 $63.68
Note that the actual amounts may vary based on geographic location and location of service.
Proposed changes are intended to simplify the consent process for CCM. They allow a provider to document that the patient consented to or declined CCM services within the medical record rather than obtaining a written agreement.
There are no changes proposed to what information must be covered when obtaining patient consent, such as the fact that only one practitioner can provide and receive payment for CCM services, and that a patient has the right to stop CCM services at any time (effective at the end of a calendar month).
It is also proposed to remove language that requires the patient to authorize electronic communication of their medical information with other treating providers as a condition of payment for CCM services. This disclosure is currently permitted under the Health Insurance Portability and Accountability Act (HIPAA) for covered entities.
CareSync acknowledges that obtaining written patient consent can place a burden on eligible providers. However, we would argue that written patient consent is the ideal standard. It is helpful in acknowledging to caregivers and others that patients want and consented to participate in CCM services. It can also ease the burden placed on providers to document that they have covered the required consent information with patients.
Initiating Visit for CCM Service
Current regulations require the billing practitioner to initiate CCM service as part of a comprehensive evaluation and management (E/M) visit, Annual Wellness Visit, or Initial Preventive Physical Examination (IPPE). Proposed 2017 changes would require a visit ONLY for patients that were new to the practice, or for patients who had not been seen in the previous year. CCM services could also be initiated concurrently with a continuing visit code when the initiation takes place face-to-face and is billed using the new code GPPP7.
Although it is proposed that an initiation visit is not required for existing patients seen within the last year, it is CareSync’s belief that, whenever possible, an initiation visit should occur face-to-face. We believe this best practice allows patients to ask questions about CCM services and make an informed decision, clearly defines the billing practitioner’s role in providing CCM services, helps the patient understand what to expect next, and ensures that comprehensive health information is collected from the start.
24/7 Access to Care and Access to the Electronic Care Plan
A proposal is included to:
Adopt CPT language for 24/7 Access to Care, which would specifically clarify that 24/7 access to care would be for “urgent” needs rather than “urgent chronic needs”
Change the requirement of providing 24/7 access to the care plan, to providing timely electronic sharing of the care plan information (not necessarily on a 24/7 basis)
Allow transmission of the care plan by fax
It is important to note that other incentives under Medicare programs continue to adopt, and promote the adoption of, Information Technology that provides interoperability and remote access to patient records after hours. It is CareSync’s belief that the following best supports the needs of patients and the best possible care coordination outcomes:
24/7 access to the care plan
Electronic exchange of meaningful data
24/7 access to clinical staff who have access to the care plan
A Critical Change for CCM Services for RHCs and FQHCs
When providing CCM services, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are currently required to have direct supervision by the practitioner over clinical staff. It is proposed to allow clinical staff to furnish CCM services “incident to” the provider under general supervision.
This change would allow RHCs and FQHCs to effectively contract with third parties to furnish CCM services, which to date has been constrained to hours that they are open due to direct supervision requirements and the staffing constraints to complete CCM service requirements. CareSync is already positioned to fulfill the CCM requirements for RHCs and FQHCs due to our infrastructure. Ask us to explain how we can start helping you now.
RHCs and FQHCs will not have the additional payment adjustment for patients requiring extensive face-to-face assessment and care planning as part of the initiating visit for CCM services. This means that new code GPPP7 is not proposed for use by RHCs and FQHCs. However, it appears that FQHCs and RHCs will be able to bill with the new severity adjusted CPT codes of 99487 and 99489 for complex CCM services.
In general, the other proposed changes listed above regarding patient consent, initiation of CCM services, 24/7 access to care and access to the electronic care plan have also been proposed for RHCs and FQHCs.