Corporate Compliance

Note from the Instructor: CMS provides additional guidance on chronic care management

Medicare Insider, May 19, 2015

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This week’s note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.  
 
CMS provided updated guidance to hospitals and practitioners on chronic care management (CCM) in two recent releases, both of which can be downloaded from the CMS website:
Although these updates are primarily aimed at physician and non-physician practitioners (NPP), there are also ramifications for outpatient hospital departments and clinics. An important point of clarification is that individuals providing CCM must have 24/7 access to the electronic care plan, rather than the entire medical record.
 
CMS also responded to a number of requests for additional information in the form of Frequently Asked Questions (FAQ). These FAQs are set out in SE1516 and cover several specific areas, including claims submission, intersection with transitional care management services, and the provision of CCM services in facility settings.
 
Background
 
There is a growing awareness and acknowledgment by both CMS and the healthcare community that care management is an important component of primary care, often leading to better outcomes, as well as cost savings. To that end, for dates of service on and after January 1, 2015, Medicare began paying practitioners under the Medicare physician fee schedule (MPFS) for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions (reported with CPT code 99490).
 
Overview of FAQs
 
The remainder of this note will focus on key information relating to CCM services furnished in hospital outpatient settings. For purposes of this discussion, such hospital outpatient settings include hospital outpatient departments, as well as provider-based departments and clinics, and will be referred to generally as “HOPDs.” This information is primarily set out in some of the above-referenced FAQs. 
 
FAQ #18. Are HOPDs eligible to bill CPT code 99490 under the OPPS?
 
Medicare will pay for CCM facility services (also reported with CPT code 99490) under the OPPS when the requirements in FAQ #19 are met. Since CPT code 99490 is defined as a physician-directed service, Medicare will pay for the CCM facility services only when the hospital’s clinical staff furnishes the services at the direction of the physician/NPP. Separate payment for the physician’s/NPP’s time spent directing CCM services in the HOPD setting is made under the MPFS at the facility rate.
 
FAQ #19. What are the requirements to bill CCM under the OPPS?
 
Since CPT code 99490 is defined as a physician-directed service, when the CCM service is furnished in an HOPD, the HOPD may only bill and be paid for the facility portion of CCM services furnished to eligible hospital outpatients under the OPPS if:
  • The hospital’s clinical staff furnishes at least 20 minutes of care management services under the direction of the physician/NPP during the calendar month; and
  • The billing physician/NPP directing the CCM services meets the requirements to bill CCM services under the MPFS set out below:
  1. Patient Eligibility—patient has two or more chronic conditions expected to last at least 12 months or until the death of the patient, placing the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
  2. Patient Agreement—patient consent to receive CCM services has been obtained by the practitioner and documented in the medical record;
  3. CCM Scope of Service Elements—all applicable Scope of Service Elements (as set out in the MPFS final rules for calendar years (CY) 2014 and 2015) are furnished by the HOPD; and
  4. CCM Certified Technology—the HOPD furnished the CCM services using a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31 of the CY preceding each Medicare MPFS payment year (referred to as “CCM Certified Technology”). The hospital must also meet the requirements to use electronic technology in providing CCM services, such as 24/7 access to the care plan, and electronic sharing of the care plan and clinical summaries (other than by fax), specified in the MPFS final rules for CYs 2014 and 2015.
FAQ # 20. How does CMS define a “hospital outpatient” for whom a hospital may bill CCM services (CPT code 99490)?
 
A hospital outpatient is generally defined as a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives outpatient services from the hospital. Since CPT code 99490 will ordinarily not be performed face-to-face, the patient will typically not be a registered outpatient when receiving the service. As noted above, in order to bill for the service, the hospital’s clinical staff must provide at least 20 minutes of facility CCM services under the direction of the billing physician/NPP. Because of the practitioner’s direct relationship with the beneficiary, he or she should inform the patient the hospital will be performing care management services under the practitioner’s direction.
 
FAQ # 21. When CCM services are furnished by a physician in a hospital outpatient department, can the physician and the hospital both bill Medicare for the CCM services?
 
When professional CCM services are furnished by a physician/NPP in an HOPD to an eligible patient, the physician/NPP may bill Medicare for payment under the MPFS, reporting CPT code 99490 and place of service 22 (outpatient hospital), which will result in payment at the facility rate. The hospital may also bill Medicare for payment of the facility CCM services under the OPPS by reporting CPT code 99490.
 
FAQ #23. Is CPT code 99490 payable to provider-based hospital outpatient departments under the hospital OPPS? May a hospital-owned practice that is not provider-based bill the OPPS for CCM services?
 
A provider-based outpatient department of a hospital is part of the hospital and, therefore, may bill for facility CCM services furnished to eligible patients, provided that it meets all applicable requirements. A hospital-owned practice that is not provider-based is not part of the hospital and, therefore, is not eligible to bill for facility services under the OPPS. The physician/NPP practicing in the hospital-owned practice, however, may bill for payment under the MPFS for professional CCM services furnished to eligible patients, provided all MPFS billing requirements are met.
 
FAQ # 24. What is the supervision level for facility CCM services furnished in the hospital setting?
 
CPT code 99490 is assigned a general supervision level under the OPPS when furnished in the HOPD setting. General supervision means the procedure is furnished under the physician's/NPP’s overall direction and control, but the physician's/NPP’s presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually perform the procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician/NPP. 
 
Interestingly, facility CCM services are considered to be outpatient hospital therapeutic services, which are generally subject to coverage requirements under the facility “incident to” a physician’s services requirements (see 42 CFR §410.27). Under these “incident to” requirements, the default level of physician/NPP supervision is “direct supervision,” which requires the supervising practitioner to be immediately available and able to furnish assistance and direction throughout the performance of the procedure. The decision to assign the lower level of general supervision to CPT code 99490 to facility CCM services was at the initiation of CMS, effective for dates of service on and after January 1, 2015.
 
Hospitals are encouraged to review the recent releases referenced above for more specific information on professional and facility CCM services.



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