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Innovations: Chronic Care Management (CCM)

CCM is care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months. Health care professionals have an opportunity to be separately paid for important services while improving Medicare patients' self-management, health outcomes, and patient satisfaction.

On this page, view the below information.

Beneficiary Eligibility

Provider Eligibility

Billing

Documentation

Pricing/Payment


Beneficiary Eligibility

  • Patients must have two or more chronic conditions (expected to last at least 12 months) with significant risk of death, functional decline, exacerbation or decompensation - E.g., hypertension, heart disease, diabetes, high cholesterol, etc.
  • Benefit expected to cover 2/3 of all Medicare beneficiaries that have these 2 or more chronic conditions

Provider Eligibility

  • Physician, nurse practitioner, physician assistant, certified nurse midwives & clinical nurse specialists, clinical staff (pharmacists, medical assistants, technicians, nurses, therapists) - Not within scope of license for podiatrists, clinical psychologists or dentists
  • Billing provider only required to furnish an Annual Wellness Visit (AWV), Initial Preventive Physical Exam (IPPE) or comprehensive Evaluation and Management (E/M) prior to billing CCM for new patients or patients not seen within last 12 months - Established patients may be contacted verbally or through email
  • Must provide "timely access" to electronic patient records
  • CCM services may be provided by clinical staff under direction of billing practitioner on an "incident to" basis (as an integral part of services provided by billing practitioner), subject to applicable State law, licensure and scope of practice
    • Clinical staff are either employees or working under contract to billing practitioner whom Medicare directly pays for CCM under "General" supervision; not the usual "Direct" supervision

Billing

  • Bill one non face-to-face code monthly
    • CPT code 99490 (20 mins.) without add on code
    • CPT code 99487 (complex 60 mins.) and if applicable 99489 (complex +30 mins.)
    • HCPCS code G0506 (comprehensive assessment – no time) if patient needs extensive visit by physician only after initiating visit (AWV, IPPE or E/M)
  • Provider bills Place of Service (POS) 11
  • Only one provider (who wrote plan of care) allowed to bill monthly
    • Spent at least 20 or 60 minutes or more (every 30 days) coordinating care
  • Time spent directly by billing practitioner or clinical staff counts toward threshold clinical staff time required to be spent during a given month to bill CCM services
    • Non-clinical staff time cannot be counted toward threshold
  • Do not bill same month as
    • Transitional Care Management (TCM) CPT codes 99495–99496
    • End Stage Renal Disease (ESRD) CPT codes 90951–90970
    • Home Health/Hospice Care HCPCS codes G0181–G0182

Documentation

Documentation must:

  • Include narrative detailing need for CCM
  • Support beneficiary eligibility
  • Include a comprehensive care plan (with measurable goals) established, implemented, revised or significantly monitored
    • Patient or caregiver must be given a copy of care plan. Medicare does not specify a certain format for care plan
  • Include the CCM discussion narrative with beneficiary and his/her (verbal (for patients who have been seen in the practice within past 12 months) or written) prior permission acceptance
    • Verbal acceptance must be documented and must be explained to patient for transparency
    • Beneficiary may terminate consent at any time
  • Support services rendered
  • Include time spent on CCM services
  • Support provision of at least 20 or 60 minutes of CCM services for month billed (based on specific procedure code billed)

Regarding the use of Certified Electronic Health Record (EHR) it is required to standardize the formatting in medical record of core clinical information (demographics, problems, medications, medication allergies, however; certified technology no longer required for other CCM documentation or transitional care management documents)

Pricing/Payment

  • $40 - $120 monthly (check your state locality fee schedule)
  • Beneficiary responsible for coinsurance/deductible

Resources

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