CPAs & ADVISORS · “We propose that a RHC or FQHC can bill for CCM services furnished by, or incident to, a RHC or FQHC physician, ... • Must use technology cer

experiencemomentum//

CPAs&ADVISORS

KentuckyPrimaryCareAssocia<on:2015FallConference

CHRONICCAREMANAGEMENT–WHATDOESTHISMEANTOYOU?

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ThefollowinginformaConwasusedasavisualaidduringapresentaCon/trainingsessionledbyaBKD,LLPadvisor.ThiscontentwasnotdesignedtobeuClized

withouttheverbalporConofthepresentaCon.Accordingly,informaConincludedontheseslides,insomecases,areonlyparCallistsofrequirements,recommendaCons,etc.andshouldnotbeconsideredcomprehensive.Thesematerialsarebeingissued

withtheunderstandingtheymustnotbeconsideredlegaladvice.

Ø  ChronicCareManagement(CCM)Services

DefinedØ  CMSRulingsØ  CCMScopeofServicesElements–

Highlights

Ø  CCMCPTCodeBillingRequirementsØ  ElectronicHealthRecord(EHR)

Requirements

Ø  HealthCenterProviderRevenuePotenCal

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CHRONICCAREMANAGEMENTDEFINEDCMSdefinesCCMas:“Chroniccaremanagementservicesfurnishedtopa4entswithmul4ple(twoormore)chroniccondi4onsexpectedtolastatleast12months,orun4lthedeathofthepa4ent,thatplacethepa4entatsignificantriskofdeath,acuteexacerba4on/decompensa4onorfunc4onaldecline.”

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CHRONICCAREDISEASEOVERVIEW(cont’d)

ChronicDiseaseDefined•  Chronicdiseaseisalong-las<ngcondi<onthatcanbecontrolledbutnotcured.

•  Condi<onisexpectedtolastatleast12monthsorun<lthedeathofthepa<ent.

•  Examplesofchroniccondi<ons:(notallinclusive)Ø  Alzheimer’sdiseaseandrelateddemen<a

Ø  AsthmaØ  CancerØ  ChronicObstruc<vePulmonaryDiseaseØ  DiabetesØ  Heartfailure

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CMSMEDICAREPHYSICIANFEESCHEDULE

CY2015FINALRULE

•  In2014,CMSfinalizedpolicies

toestablishseparatepaymentsforCCMservices

•  DidnotincludeFQHCandRHCproviders

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CMSCY2016PROPOSEDRULE

CMSCY2016ProposedRulestates:“Thisproposedruleproposestoprovideanaddi<onalpaymentforthecostsofCCMservicesthatarenotalreadycapturedintheRHCAIRortheFQHCPPSpayment,beginningonJanuary1,2016.ServicesthatarecurrentlybeingfurnishedandpaidundertheRHCAIRorFQHCPPSpaymentmethodologywillnotbeaffectedbytheabilityoftheRHCorFQHCtoreceivepaymentforaddi<onalservicesthatarenotincludedintheRHCAIRorFQHCPPS.”“TherequirementsweareproposingforRHCsandFQHCstoreceivepaymentforCCMservicesareconsistentwiththosefinalizedintheCY2015PFSfinalrulewithcommentperiodforprac<<onersbillingunderthePFSandaresummarizedinTable17.Weproposetoestablishpayment,beginningonJanuary1,2016,forRHCsandFQHCswhofurnishaminimumof20minutesofqualifyingCCMservicesduringacalendarmonthtopa<entswithmul<ple(twoormore)chroniccondi<onsthatareexpectedtolastatleast12monthsorun<lthedeathofthepa<ent,andthatplacethepa<entatsignificantriskofdeath,acuteexacerba<on/decompensa<on,orfunc<onaldecline.”“WeproposethataRHCorFQHCcanbillforCCMservicesfurnishedby,orincidentto,aRHCorFQHCphysician,nurseprac<<oner,physicianassistant,orcer<fiednursemidwifeforaRHCorFQHCpa<entoncepermonth,andthatonlyoneCCMpaymentperbeneficiarypermonthcanbepaid.”

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CMSCY2016PROPOSEDRULE,CONT.

CMSCY2016ProposedRulestates:“InconsideringCCMpaymentforRHCsandFQHCs,webelievethatthenon-face-to-face<merequiredtocoordinatecareisalsonotcapturedintheRHCAIRortheFQHCPPSpayment,par<cularlyfortheruraland/orlow-incomepopula<onsservedbyRHCsandFQHCs.AllowingseparatepaymentforCCMservicesinRHCsandFQHCsisintendedtoreflecttheaddi<onalresourcesnecessaryfortheuniqueservicesthatarerequiredinordertofurnishCCMservicesthatarenotalreadycapturedintheRHCAIRortheFQHCPPSpayment.“

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CMSCY2016ProposedRuleSummary•  Effec<veJanuary1,2016,intheproposedrule,physiciansbillingunderthePPS

wereeligibletoreceiveseparatepaymentforCCMservices.

•  WouldallowRHCsandFQHCstoreceiveseparatepaymentforCCMservices

•  ProposedCCMpaymentswouldnotbeincludedin:Ø  RHCsall-inclusiverate(AIR)Ø  FQHCs’PPS

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CCMSCOPEOFSERVICECCMservicerequirementsinclude,butarenotlimitedto,thefollowing:•  CCMservicesini<a<onduringanannualwellvisit(AWV),Ini<alPreven<ve

PhysicalExam(IPPE)orcomprehensiveE/Mvisit(billedseparately).•  Accesstocaremanagementservices24-hour-a-day,7day-aweekaccess.•  Con<nuityofcare•  CareManagementforchroniccondi<ons•  Crea<onofapa<ent-centeredcareplan•  Managementofcaretransi<ons•  Coordina<onwithhomeandcommunitybasedclinicalserviceproviders•  Enhancedcommunica<onopportuni<esforpa<entsand/orcaregivers•  Electroncaptureandsharingofcareplaninforma<on

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CCMSCOPEOFSERVICE

•  Accesstocaremanagementservices24-hour-a-day,7day-aweekaccess.

Ø Providingpa<entswithameanstomake<melycontactprovidersorclinicalstafftoaddressurgentchroniccareneedsregardlessofthe<meofdayordayoftheweek.

•  Con<nuityofcareØ Thepa<entmustbeabletogetsuccessiverou<neappointmentwithdesignatedprovideroramemberofthecareteam.

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CCMSCOPEOFSERVICE

•  CareManagementforchroniccondi<onsØ  Systema<cassessmentofapa<ent’smedical,func<onal,andpsychosocial

needs,Ø  System-basedapproachestoensure<melyreceiptofallrecommended

preven<vecareservices,Ø  Medica<onreconcilia<onØ  Oversightofpa<entself-managementofmedica<ons.

•  Crea<onofapa<ent-centeredcareplan

Ø  Basedonaphysical,mental,cogni<ve,psychosocial,func<onal,andenvironmental(re)assessmentandaninventoryofresourcesandsupports.

Ø  Itisacomprehensiveplanofcareforallhealthissues.

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CCMSCOPEOFSERVICE

•  Crea<onofapa<ent-centeredcareplan,Ø Ittypicallyincludes,butnotlimitedto:

ü  Problemlist

ü  Expectedoutcomeandprognosis

ü Measurabletreatmentgoals

ü  Symptommanagement

ü  Plannedinterven<onsandiden<fica<onoftheindividualsresponsibleforeachinterven<on

ü Medica<onmanagement

ü  Community/socialservicesordered

ü  Scheduleforperiodicreviewandrevisionofplan(whenapplicable)

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CCMSCOPEOFSERVICE

•  Managementofcaretransi<onsØ  Referralstootherclinicians,Ø  Follow-upaherapa<entvisittoanemergencydepartment,Ø  Follow-upaherapa<entdischargefromahospital,skillednursingfacility,or

otherhealthcarefacility.

•  Coordina<onwithhomeandcommunitybasedclinicalserviceprovidersØ  Toensureappropriatesupportofapa<ent’spsychosocialneedsandfunc<onal

deficitØ  Communica<ontoandfromtheseprovidersmustbedocumentedintheEHR

usingCCMcer<fiedtechnology

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CCMSCOPEOFSERVICE

•  Enhancedcommunica<onopportuni<esforpa<entsand/orcaregiversØ  Communica<onwiththeprac<<onerregardingthebeneficiary’scarethrough

telephone,securemessaging,secureinternetorotherasynchronousnonface-to-faceconsulta<onmethods(subjecttoHIPAA)

•  Electroniccaptureandsharingofcareplaninforma<onØ  Availableona24/7basistoallproviderswithintheprac<cewhoarefurnishing

CCMservicesandwhose<mecountstowardthe<merequirementforbillingtheCCMcode.

Ø  Sharedelectronically(otherthanbyfacsimile)asappropriatewithotherproviderswhoarefurnishingcaretothebeneficiary.

Ø  Mustprovidethepa<entawrijenorelectroniccopyofthecareplanandtodocumentintheEHRthatthiswasdone.

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ELIGIBLEBENEFICIARY

AqualifiedMedicarebeneficiarymusthave:•  Twoormorechroniccondi<ons

Ø  Nodefini<velist•  Musthaveachroniccondi<onexpectedtolastatleast12months,orun<lthe

deathofthepa<ent;placespa<entatsignificantriskofdeath,acuteexacerba<on/decompensa<onorfunc<onaldecline.

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BENEFICIARYAGREEMENT

•  GenngMedicareBeneficiaryagreementincludes,butnotlimitedto:

Ø  Informthepa<entoftheavailabilityofCCMservicesandobtainhisorherwrijenagreementtohavetheservicesprovided.

Ø  Informthepa<entthatonlyoneprovidercanfurnishandbepaidforCCMinacalendarmonth.

Ø  Documentinthepa<ent’smedicalrecordthatalloftheCCMserviceswereexplainedandofferedtothepa<ent,andnotethepa<ent’sdecisiontoacceptordeclinetheseservices.

Ø  Clinicmustcollectasignedpa<entagreementbeforebillingCCMØ  Informthepa<entoftherighttostopCCMservicesatany<me.Ø  Informthatcostsharingapplies.

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CCMCODINGANDBILLINGREQUIREMENTS

ChronicCareManagement(CPT99490)AccordingtotheCMSChronicCareManagementFactSheet,CPT99490isdefinedas

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CCMCODINGANDBILLINGREQUIREMENTS

WhoCanFurnishCCM:•  Non-physicianprac<<oners(NPP)suchasnurseprac<<oner,physician

assistants,clinicalnursespecialistsandcer<fiedmidwives,canfurnishandbillMedicareforCCM,butonlytotheextentpermijedundertheirscopeofprac<ce.

•  OtherNPP,suchasclinicalpsychologistsandsocialworkers,arenoteligible

tobill.•  CMSwillreimburseonlyoneprac<<onerforprovidingCCMservicesper

calendarmonthandcanonlybebilledwhenatleast20minutesofnon-face-to-facecarecoordina<onservicesareprovided.

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CCMCODINGANDBILLINGREQUIREMENTS

•  Codes/servicesthatcannotbereportedduringthesamemonthasCCM:

Ø  Transi<onalcaremanagement(CPTcodes99495–99496)

Ø  Homehealthandhospicecaresupervision(HCPCScodesG0181–G0182)

Ø  End-stagerenaldiseaseservice(CPTcodes90951–90970)

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CCMTECHNOLOGYREQUIREMENTS

•  Cer<fiedEHRmustbeusedfortherecordingofdemographicinforma<on,health-relatedproblems,medica<ons,andmedica<onallergies;aclinicalsummaryrecord;andotherscopeofservicerequirementsthatreferenceahealthormedicalrecord

•  Mustusetechnologycer<fiedtotheedi<on(s)ofcer<fica<oncriteriathatis,ataminimum,acceptablefortheEHRIncen<veProgramsasofDecember31stoftheyearprecedingeachCCMpaymentyear

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CCMTECHNOLOGYREQUIREMENTS

  Structuredrecordingofdemographics,problems,medica<ons,medica<onallergies,andcrea<onofstructuredclinicalsummaryrecordsusingCCMcer<fiedtechnology.

  DocumentprovisionofthecareplanasrequiredtothebeneficiaryintheEHRusingCCMcer<fiedtechnology.

  FormatclinicalsummariesaccordingtoCCMcer<fiedtechnology.Notrequiredtouseaspecifictoolorservicetoexchange/transmitclinicalsummaries,aslongastheyaretransmijedelectronically(otherthanbyfax).

  Communica<ontoandfromhomeandcommunitybasedprovidersregardingthepa<ent'spsychosocialneedsandfunc<onaldeficitsmustbedocumentedinthepa<ent'smedicalrecordusingCCMcer<fiedtechnology

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1.QUALIFIEDPROFESSIONALS

WhichpracCConersareeligibletobillMedicareforCCM?

Ø  Physicians

Ø  Cer<fiedNurseMidwives

Ø  ClinicalNurseSpecialists

Ø  NursePrac<<oners

Ø  PhysicianAssistants

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AqualifiedMedicarebeneficiarymusthave:•  Twoormorechroniccondi<ons

Ø  Nodefini<velist•  Achroniccondi<onexpectedtolastatleast12months,or

un<lthedeathofthepa<ent;placespa<entatsignificantriskofdeath,acuteexacerba<on/decompensa<onorfunc<onaldecline.

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2.QUALIFIEDMEDICAREBENEFICIARIES

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3.MEDICAREBENEFICIARYCONSENT

•  AprovidercannotbillforCCMservicesunlesshe/shesecuresawrijenconsentfromthebeneficiary.

•  Beneficiarymustacknowledgeproviderhasexplained(listnot

allinclusive):

Ø  CCMprogram

Ø  MannerinwhichCCMserviceswillbeprovided

Ø  Healthinforma<onwillbesharedwithotherprac<<oners

Ø  Onlyoneprac<<onercanprovidetheseservicesduringacalendarmonth

Ø  BeneficiaryhastherighttostopCCMservicesatany<me

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4.NON-FACE-TO-FACECAREMANAGEMENTSERVICES

•  Typeofservices(nonexclusive)

Ø  Performingmedica<onreconcilia<on,oversightofbeneficiaryself-managementofmedica<ons

Ø  Ensuringreceiptofallrecommendedpreven<veservices

Ø  Monitorbeneficiary’scondi<on(mental,physicalandsocial)

•  Documenta<onmustinclude:

Ø  Dateand<me

Ø  Personfurnishingservices

Ø  Descrip<onofservices

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5.COMPREHENSIVECAREPLAN

Ø  Createapa<ent-centeredcareplanbasedonphysical,mentalcogni<ve,psychosocial,func<onalandenvironmental(re)assessmentandaninventoryofresources(acomprehensiveplanofcareforallhealthissues).

Ø  Providethepa<entwithawrijenorelectroniccopyofthecareplananddocumentitsprovisioninthemedicalrecord

Ø  Ensurethecareplanisavailableelectronicallyatall<mestoanyonewithintheprac<ceprovidingCCMservice

Ø  Sharethecareplanelectronicallyoutsidetheprac<ceasappropriate

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5.COMPREHENSIVECAREPLAN,CONT.

Ø  Typicallyincludes(notlimitedto):Ø  Problemlist

Ø  Expectedoutcomeandprognosis

Ø Measurabletreatmentgoals

Ø  Symptommanagement

Ø  Plannedinterven<onsandiden<fica<onoftheindividualsresponsibleforeachinterven<on

Ø Medica<onmanagement

Ø  Community/socialservicesordered

Ø  Scheduleforperiodicreviewandrevisionofplan(whenapplicable)

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6.CCMCERTIFIEDTECHNOLOGY

Ø  Requirestheuseofcer<fiedEHRtechnologytosa<sfymanyoftheCCMscopeofserviceelements

Ø  Useofaversionofcer<fiedEHRthatisacceptableundertheEHRincen<veprogramsasofDecember31stofthecalendaryearprecedingeachMedicarePFSpaymentyearØ  Forexample,technologyusedtofurnishCCMservices

beginningonJanuary1,2016,wouldberequiredtomeet,ataminimum,therequirementsincludedinthe2014Edi<oncer<fica<oncriteria.

Ø  hjp://www.cms.gov/Regula<ons-and-Guidance/Legisla<on/EHRIncen<vePrograms

CCMTECHNOLOGYREQUIREMENTS

EHRTechnologyRequirements:

•  Mustu<lize“CMScer<fiedtechnology”forspecifiedpurposesinprovidingCCMservices

•  Electronicallyrecordpa<entdata (i.e.,pa)entdemographicinforma)on;problemlist,medica)onsandmedica)onallergies,etc.)

•  Allowforthecrea<onofastructuredclinicalsummary

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CCMTECHNOLOGYREQUIREMENTS

EHRTechnologyRequirements(cont’d)•  Providermustbeabletotransmitthesummaryrecordforpurposesofcare

coordina<on.•  HousethebeneficiaryconsentofCCMservices.•  Housethebeneficiaryreceiptofcareplan.

•  Documentcommunica<ontoandfromhome-basedandcommunity-basedproviders.

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CCMTECHNOLOGYREQUIREMENTS

ElectronicCarePlanRequirements•  Planmustbeelectronicallyaccessible24/7toallcareteammembersinthehealth

centersthatareprovidingCCMservices.•  Careplaninforma<onmustalsobeshared,asappropriate,withotherproviders

caringforthebeneficiary.•  Abilitytoprovidepaperorelectroniccopytobeneficiary.

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CCMBILLINGANDCPTCODEREQUIREMENTS

ChronicCareManagement(CPT99490)AccordingtotheCMSChronicCareManagementFactSheet,CPT99490isdefinedas

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CCMBILLINGANDCPTCODEREQUIREMENTS

BillingCCMServices•  CMSadoptedCPT99490forrepor<ngatleast20minutesofCCMpermonth.

•  Non-physicianprac<<oners(NPP)suchasnurseprac<<oner,physicianassistants,clinicalnursespecialistsandcer<fiedmidwives,canfurnishandbillMedicareforCCM,butonlytotheextentpermijedundertheirscopeofprac<ce.

•  OtherNPP,suchasclinicalpsychologistsandsocialworkers,arenoteligibletobill.•  CMSwillreimburseonlyoneprac<<onerforprovidingCCMservicespercalendar

monthandcanonlybebilledwhenatleast20minutesofnon-face-to-facecarecoordina<onservicesareprovided.

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CCMBILLINGANDCPTCODEREQUIREMENTS

BillingCCMService(cont’d)§  Codes/servicesthatcannotbereportedduringthesamemonthasCCM:

Ø  Transi<onalcaremanagement(CPTcodes99495–99496)

Ø  Homehealthandhospicecaresupervision(HCPCScodesG0181–G0182)

Ø  End-stagerenaldiseaseservice(CPTcodes90951–90970)Ø  OverlapwithCMSdemonstra<onorotherini<a<vesthatpayforsimilar

services

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PROVIDERHEALTHCENTERREVENUEPOTENTIAL

PotenCalRevenuePerProvider•  Basedonthena<onaldata,thetablebelowcalculatestherevenuepoten<alforasingle

providerbillingforCPT99490.IfaproviderperformsCCMservicesfortheircensusofqualifiedMedicarepa<ents,theiraddi<onalrevenuepoten<alissubstan<al.

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CONCLUSION

ThenewrulefromCMSallowingreimbursementforCCMservicesisahugechangethatwillallowphysiciansto:•  Improvepa<entcareforMedicare

beneficiariesdealingwithchronicdiseases

•  Nowgetpaidforworktheyarealreadydoingtocareforchronicallyillpa<ents

•  Poten<allyincreaserevenuefortheirhealthcenterproviders.

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Office: 417.865.8701 Fax: 417.865.0682 www.bkd.com

Jacqueline R. Todd-Washington, BSM Managing Consultant jwashington@bkd.com

Rebekah S. Wallace Pardeck, CMPE, CPC, MCS-P Director rwallace@bkd.com

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DISCLAIMER

Theinforma<oncontainedinthispresenta<onisnotintendedtocoverallsitua<onsorallrulesandpolicies.Reimbursementlaws,regula<onsandpoliciesaresubjecttochange.

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