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Chronic Care Management (CCM) Questions and Answers

Last Updated November 2017

Q1. Is the billing provider also the same provider who initially conducted the beneficiary visit?
A1. Yes. The eligible provider is required to furnish, in advance, either an Annual Wellness Visit (AWV), Initial Preventive Physical Exam (IPPE) or Evaluation and Management (E/M) visit, prior to billing CCM, for each eligible beneficiary. If the practitioner furnishes one of those visits and does not discuss CCM with the beneficiary without documenting, then it cannot count as the CCM initiating visit.   

Q2. Does the physician have to sign the care plan? Can a Licensed Practical Nurse (LPN) create the plan of care (POC) and have the physician sign off?
A2. Yes and no. An LPN or Registered Nurse (RN) may have their services documented toward the monthly CCM, but may not develop the POC. The RN/LPN may revise, monitor and continue the POC. All documents are signed and dated by the practitioner billing the service. The Electronic Medical Record (EMR) should contain the documentation for the scope of service rendered.

Q3. How often does a care plan need to be written and the beneficiary sign the consent form? Do providers have to provide a care plan every time we render the 20 minute non-face-to-face time?
A3. A care plan is needed for every CCM billing monthly. Providers do not have to submit the plan with their claim; however, it should be kept in the beneficiary's chart records. The consent form is obtained once prior to furnishing the CCM services or if the beneficiary chooses to change the practitioner who will furnish and bill the service.

Q4. Do measurable goals for each chronic condition need to be listed in the care plan? Are there published documentation requirements for the POC component? How detailed should the notes be to justify 20 minutes of staff time under CCM?
A4. Yes, measureable goals and detailed notes need to be listed. POC documentation requirements can be found in this CMS link under Chronic Care Management Services This link takes you to an external website..

Q5. When a patient is admitted to a hospital or a skilled nursing facility (SNF), is the CCM provider required to send anything to the facility?
A5. Providers need to coordinate with the SNF or hospital and provide information if requested.

Q6. Is there a way to check if another provider is already providing CCM services to patients? Can another provider bill for the services listed during the same month?
A6. No. Providers could ask the patient if they have another primary care physician who may be providing CCM. Only the physician or provider who obtained the written consent can bill for the services.

Q7. Can a Certified Medical Assistant (CMA) or a Registered Nurse have the discussion with the patient?
A7. All clinical staff within their scope of service can be involved in the discussion with the patient and have their time counted towards the monthly service. A reminder that non-clinical staff time cannot aggregate their time to meet the 20-minute minimum.

Q8. Can licensed clinical social workers (LCSWs) and nursing staff (including hospital based clinics) time count toward the 20 minutes? How about employed or contracted pharmacists that provide medication management? What if they are clinical pharmacists who work in the ambulatory setting?
A8. Yes. LCSWs, nursing staff and pharmacists that are employed by the group can be counted toward the 20 minute service, as long as what s/he is doing is within their scope of practice, like medication management. Since pharmacists cannot bill directly for their services, providers may contract with the pharmacists in either an Ambulatory Surgical Center (ASC) setting or within their practice.

Q9. Are providers outside of our organization (e.g. home health, etc.) required to have access to our EMR? Are we required to have e-mail access for our patients to qualify? 
A9. Shared information is to be sent when requested. If providers are not on the same EMR system, CMS currently does not require the use of certified EMR technology for some of the services involving the care plan or clinical summaries. There must be timely contact with health care practitioners who have patient’s health record access and that can address his or her urgent chronic care needs.

Q10. With a Provider-Based Billing (PBB) clinic, does the hospital’s clinical staff (RN, MA, pharmacist, etc.) time count towards the 20 minutes?
A10. Yes, the time counts and all supporting documentation should be available upon request. From Special Edition (SE) 1516, a provider-based outpatient department may bill for CCM services furnished to eligible patients, provided that it meets all applicable requirements, under the hospital Outpatient Prospective Payment System (OPPS). The payment for the CCM will trigger payment at the facility rate. If the patient resides in a community setting and the CCM service is provided by or “incident to” services of the billing physician, or other appropriate billing practitioner working in or employed by a hospital, CPT 99490 can be billed to the physician fee schedule (PFS).

Provider-based status means the relationship between a main provider This link takes you to an external website. and a provider-based entity This link takes you to an external website. or a department of a providerThis link takes you to an external website., remote location of a hospital This link takes you to an external website. or satellite facility This link takes you to an external website., that complies with the provisions. In the PBB model, patients may receive two charges on their combined patient bill for services provided within a clinic. One charge represents the facility charge and the other represents the professional or physician fee.

Q11. If the patient consent needs updating (provider retires), can the communication be via phone or does the patient need to be seen in person?
A11. The new provider should initiate communication in person (e.g., E/M visit, etc.). It doesn’t matter if the provider is retiring, leaving the practice or the patient wants to see a new provider, the final rule (78 FR 74424) states a new consent is required if the patient changes billing practitioners. A new consent must be obtained and documented prior to furnishing the CCM service.

Q12. Can the provider waive the coinsurance for the beneficiary if they choose?
A12. No. This would be an Anti-Kickback violation.

Q13. For the written document of consent, is there a standardized form recommended by CMS or Noridian for physician offices to use?
A13. There is no formal document of consent from CMS; however, below are the patient consent requirements needed to bill for this service.

  • Explanation of CCM service
  • Inform patient of CCM service availability and obtain written agreement for services provided, including authorization for electronic communication of medical information with other treating practitioners and providers
  • Explain and offer CCM service to the patient, document this discussion and note  patient's decision to accept or decline
  • Explain how to revoke the service
  • Inform patient only one practitioner can furnish and be paid for the service once during a calendar month
  • Explain there will be coinsurance and any unmet deductible applied

Q14. Does leaving a message via phone or secure messaging qualify as communication towards the 20-minute consultation?
A14. No. Since Medicare CCM does not allow for “leaving messages” towards the CCM monthly time. It does not meet the scope of service as a communication with the patient. The time spent by the staff researching and leaving messages would not be covered towards the 20 minutes.
Q15. Does preventive care (unrelated to the CCM) count towards the 20 minutes (i.e. history of breast cancer and call to order the mammogram or knee surgery follow-up call)?
A15. No. Providers would be including that information in beneficiary’s records.

Q16. If beneficiaries come into the office for abnormal lab results to discuss treatment options, would providers bill the E/M in the same month as the CCM? Are the lab results a part of the post work of an E/M and does communicating lab results one or two days post-appointment count for CCM? Is the 20 minutes inclusive for the chronic conditions (i.e. mammography results, etc.)?
A16. Yes to all of the above questions.

Q17. Is CCM billed when a patient comes into the office for an acute visit or follow up for their chronic condition to discuss lab results, etc.?
A17. No. This may count towards CCM, but CCM is a non-face-to-face billing code. Providers would not add a 99490 on the same day as the E/M visit.

Q18. Do providers document a start and stop time or total minutes?
A18. Total minutes are acceptable. 

Q19. Will the 2017 Medicare Access and Chip Reauthorization Act (MACRA) affect CCM?
A19. No, but the 2017 Federal Rule may update CCM. Section 103 of the MACRA codifies payment broadly for CCM services under the physician fee schedule (PFS). Authorizing payment does not impact the current billing and payment rules for CPT 99490. The provision of an AWV, IPPE or E/M in advance shall not be a condition of payment for CCM services, which is consistent with our current policy.

Q20. Does Medicare have a sample CCM plan?
A20. No. It’s up to the provider to create a form and summarize with the following:

  • Problem list and assessments
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions and identification of individuals responsible for each intervention
  • Monitoring a patient’s physical, mental and social needs
  • Ensuring timely receipt of preventive care services
  • Supervising the patient’s medication self-management and reconciliation
  • Description of how services of agencies and specialists outside the practice will be directed/coordinated

Q21. If providers bill for the CCM and later realize that the patient is also eligible for Transitional Care Management (TCM) or End Stage Renal Disease (ESRD) services, can we void or correct our billing to remove the CCM and bill the other code?
A21. Yes. Providers need to refund the monies to Medicare first, wait for that remittance transaction and then rebill the monthly CCM code. The best practice may be to wait until the end of the month to see which code the practice should bill.

Q22. In the outpatient setting, after we have met the criteria and submitted the billing, how do we verify which documents are eligible to support those 20 minutes, if there are acute visits in between?
A22. Providers would have separate documentation on the patient for CCM and any other visits, services or procedures.

Last Updated Nov 13, 2017