The chronically ill account for a huge percentage of the population. In fact, as of 2012, approximately one half of all adults had one or more chronic health conditions, and one in four adults had two or more chronic health conditions. Additionally, heart disease and cancer—both chronic diseases—together accounted for almost half of all deaths in 2010. Given these facts, is it any surprise that, in 2010, eighty-six percent of all health care spending was for people with one or more chronic medical conditions? (source here)
As of January 1st, 2016, Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) are able to bill for Chronic Care Management (CCM) services provided to Medicare patients using CPT code 99490. CCM refers to the non-face-to-face coordination of care for chronically ill patients.
In addition to being a step in the right direction for patient care, this is a great opportunity for additional revenue for many health centers. However, there are numerous requirements that need to be met in order to bill for CCM. If you plan on incorporating CCM services into your health center, you’ll want to check out the resources at the bottom of this post, but here’s a high-level overview.
PATIENT ELIGIBILITY
Eligible patients are Medicare beneficiaries with two or more chronic conditions.
Chronic conditions are defined as those that “place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline” and are “expected to last at least 12 months, or until the death of the patient” (from CMS’ MLN Chronic Care Management Services guide).
REQUIREMENTS
Prior to performing CCM services, the provider must furnish a comprehensive E&M visit, Annual Wellness Visit, or Initial Preventive Physical Examination, the patient must be properly informed about the nature of CCM services (including how to revoke the service if desired) and written consent must be obtained from the patient.
There are numerous requirements regarding Electronic Health Records and the scope of services provided, which must be met by the provider. Following is a sampling of the scope of service elements (see CMS’ MLN Matters MM9234 for a comprehensive list of scope of service and EHR/technology requirements):
Creation of a patient-centered care plan based on a comprehensive assessment and inventory of resources;
Ensure that the plan is available electronically at all times to anyone within the practice providing CCM services;
Provide enhanced opportunities for patient or caregiver to communicate with provider regarding patient’s care (e.g. telephone, secure messaging, secure internet, etc.)
Ensure 24/7 access to care management services. Some examples of care management services include:
Medication reconciliation with review of adherence and potential interactions;
Follow-up after an emergency department visit or discharge from hospital/skilled nursing facility;
Coordination of care with home and community based clinical service providers.
BILLING
The 2016 rate for CCM services in FQHCs and RHCs is $40.82 (there is no geographic adjustment).
The patient’s coinsurance/deductible applies to CCM services.
CCM services can be billed a maximum of once per month, and a minimum of 20 minutes per month must be spent on CCM services in order to bill for them.
Only one provider may be paid for CCM services for a patient in a given month.
CCM services may be billed as a stand-alone service or in conjunction with a billable visit.
If you want to learn more about incorporating CCM services into your health center, contact FQHC Associates here, and we’ll work with you to come up with a strategy that fits your needs.
References/Resources
MLN Chronic Care Management Services guide
Chronic Care Management (CCM) Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Frequently Asked Questions (from CMS.gov)
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