CMS has finally made chronic care management is reimbursable. Learn how your PCMH and care coordination efforts can now be billed.

1. Reimbursing Chronic Care Management (CCM)
Wednesday, October 29th, 2014
Disclaimer: Nothing that we are sharing is intended as legally binding or prescriptive advice. This
presentation is a synthesis of publically available information and best practices.

2. The concept has always sounded simple; reduce
costs and improve care.

3. It’s been proven that Care Management of chronic disease
accomplishes both, so why were Care Management programs
unpopular?
Lack of Payment
• Most payers bundle payment for non-face-to-face
interaction.
Costs
• Staff
• Technology
• Time
Software Limitations
• Care Management limitations in PM systems and
integrated tools were lacking

4. Is there any clearer message?
CMS will be reimbursing providers for Care Management services Effective
January 1, 2015.
CMS acknowledged that 75% of our healthcare spending is directly related to
chronic conditions. It sends a clear message that the costs associated with
chronic disease drives the decision to encourage care management in our
society.

5. Non-face-to-face (NF2F)
Often times, the following items below were viewed as
bundled into the E&M codes. It has since been recognized
that the items were under valued and an important part of
the care management of the patient:
Work that includes answering patient phone messages
Work that includes answering patient electronic messages
 Sorting through formulary changes
Responding to labs or consultation recommendations
Providing weekend coverage.
Providing night emergency coverage

6. The Policy
 No Longer Bundled
• When billed with the following services:
• E&M
• AWV
• IPPE
• Separate payment for non-face-to-face chronic care management
services for Medicare beneficiaries
 Bundled
• When Billed with the following services:
• Home Health
• Hospice
• TCM
• Nursing Home
 Criteria
• Medicare patient
• Expected to live 12 months or until death
• Multiple, significant chronic conditions (two or more)

7. Reimbursement
Reimbursement
• Roughly $42.00
• Subject to Co-Payment
• Time Based- 20 Min
• HCPCS Code to be released in November
Submission
• Once per month, per qualified patient provided that medical
needs of the patient involve the following as it relates to the
care plan:
• Establishing
• Implementing
• Revising
• Monitoring

8. Requirements
Documentation in the patient’s medical record that all of the
chronic care management services were explained and
accepted by the patient
• Document Time and Service Provided
 A written agreement that electronic communication of the
patient’s information with other treating providers is part of
care coordination
 Information about the availability of the services from the
practitioner
 A written or electronic copy of the care plan that is provided to
the beneficiary and recorded in the electronic health record
(EHR).

9. Stipulated Services
Though it’s anticipated that there will be additional
requirements forthcoming, the list below are identified as
expectations for CCM:
Continuity of care with a clinician or practice
Care management that provides the following:
• A systematic assessment of medical, functional,
and psychosocial needs
• A system-based approach for timely delivery of
preventive services
• Medication reconciliation
• prescription and nonprescription
• review of interactions and adherence

10. Stipulated Services
The creation of an updatable patient-centered plan of care
Management of all care transitions
An EHR that is available 24/7 to both the the caregiver as well as
the patient.
Opportunities for patient-to provider communication via
telephone or secure asynchronous NF2F messaging

11. Where do you begin?
Identify patients that meet the minimum criteria
 Begin the communication
Establish your written protocols
Identify the appropriate staff who comprise your clinical care
management team.
Pursue PCMH designation
Establish your strategy

12. Q&A
Shawna.matonis@quirkhealthcare.com