Chronic Care Management (CCM) Questions and Answers
Last Updated February 2017
Q1. Can a provider choose to waive the coinsurance for a beneficiary?
A1. No. This would be an Anti-Kickback Statute violation. A provider may not waive the coinsurance or deductible on a routine basis. Only in cases of financial hardship may a provider waive any amounts. A provider who routinely waives these amounts may be in violation of the false claim act as well. Any amount deducted from the patient's bill should also be deducted from the amount billed to Medicare.
Q2. Can CMS change the Part B cost sharing requirement for the beneficiary?
A2. CMS or Noridian Medicare cannot change the cost requirements as these rules are legislated.
Q3. When contacting the patient and leaving a voicemail, is the time spent looking up the patient and making the phone call count as time spent for the 20 minutes? Can we bill if the care plan is created and no contact was made with the patient after multiple attempts that equal 20 minutes or more?
A3. Providers could not bill CCM if no contact has been made with the patient and they have not received permission. There would be no reason to create a care plan until a provider knows that the patient has provided permission.
Q4. Do telephone calls include calls to patients?
A4. CCM includes in large part, activities that are not typically or ordinarily furnished face-to-face with the beneficiary and others, such as telephone communication, review of medical records, test results and coordination and exchange of health information with other practitioners and providers.
Q5. Could a Care Plan Oversight (CPO) service be billed by another provider (in the same medical group) who did not rendered CCM?
A5. If the "countable services" for the two monthly codes do not overlap, then CPO should be allowed by another provider overseeing the care. With CPO, an attending physician is one who has been identified by the patient or beneficiary, at the time s/he elects hospice coverage, as having the most significant role in the determination and delivery of their medical care. These physicians/practitioners are not paid or employed by the hospice.
Q6. Can a Certified Medical Assistant (CMA) or a Registered Nurse (RN) have the discussion with the patient?
A6. All clinical staff within their scope of service can be involved in the discussion with the patient. Non-clinical staff time cannot be aggregated to meet the 20-minute minimum.
Q7. For the written document of consent, is there a standardized form recommended by CMS or Noridian for physician offices to use?
A7. There is no formal document of consent from CMS but 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
- Offer CCM service to the patient, document this discussion and note patient's decision to accept or decline and how to revoke the monthly service
- Inform patient only one practitioner can furnish and paid once during a calendar month
- Explain there will be coinsurance and any unmet deductible applied monthly
Q8. Should providers document a start and stop time or total minutes?
A8. Total minutes are acceptable.
Q9. 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?
A9. 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 at their practice.
Q10. If a provider bills for the CCM and later realizes that the patient is also eligible for Transitional Care Management (TCM) or End Stage Renal Disease (ESRD) services, is it appropriate for the provider to void or correct the billing to remove the CCM and bill the other code?
A10. Yes. Providers must 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.
Q11. With a Provider-Based Billing (PBB) clinic, does the hospital's clinical staff (RN, MA, pharmacist, etc.) time count towards the 20 minutes?
A11. Yes. The time counts and all supporting documentation should be available upon request. From CMS Medicare Learning Network (MLN) Matters 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 and a provider-based entity or a department of a provider , remote location of a hospital or satellite facility , 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.
Q12. Does Medicare have a sample CCM plan?
A12. 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
Q13. Can we count the time for our non-employed pharmacists and behavioral health professionals seeing patients in our office?
A13. Subject to applicable State law, licensure and scope of practice, the clinical staff are either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM. Time spent directly by the billing practitioner or clinical staff counts toward the threshold clinical staff time required to be spent during a given month in order to bill CCM services. Non-clinical staff time cannot be counted toward the threshold.
Q14. How do we coordinate CCM with transitory care after discharge from hospital?
A14. CCM could be billed during the same calendar month as the monthly Transitional Care Management (TCM), if the TCM service period ends before the end of a given calendar month and at least 20 minutes of qualifying CCM services are subsequently provided during that month. However, Medicare expects that the majority of the time, CCM and TCM will not be billed during the same calendar month.
Q15. Is an outpatient facility-based clinic (attached to the hospital) providing outpatient clinic services place of service (POS) 22, billable for CCM? Since incident to requirements exclude support staff from billing, would CCM ever be allowed in the facility-based clinic?
A15. Yes, if this is a clinic where a patient is seen regularly like any other office visit and this physician is the patient's primary care physician (PCP). However, billing practitioners in hospital-owned outpatient practices that are not provider-based departments are working in a non-facility setting and may therefore bill CCM and be paid under the physician fee schedule (PFS) at the non-facility rate.
Q16. Can a Physician's Assistant (PA) or Nurse Practitioner (NP) initiate CCM?
A16. Yes, if they are the primary care plan provider.
Q17. Does the risk factor play into the medical complexity for 99487? Is complexity based on time only?
A17. Yes, 99487 is medical decision making of moderate to high complexity. No, time is a factor, but there are work factors like ongoing oversight, direction and management that document the complexity.
Q18. Could a nephrologist perform this service for patients receiving dialysis and bill the monthly CCM?
A18. Yes, if the nephrologist is the patient's primary care physician (PCP).
Q19. Does Noridian have a documentation guide on required elements for the G0506?
A19. Not a documentation guide per se; however, only appended with certain beneficiaries that will take that unusual amount of extra time and assessment on behalf of the primary provider. CMS cautions providers that G0506 is only used if time and effort for the care plan is beyond the efforts needed in the initial code.
Q20. When providers add the G0506 to the initiating visit, would this be billed for every patient who is starting with CCM?
A20. No. This add on code is only billed when the physician personally performs extensive assessment and CCM care planning beyond the usual effort described in the initiating visit.
Q21. When G0506 is billed with an E/M code, do we need a modifier 25 appended to the E/M code? Is there a time requirement for billing G0506 and can it be billed more than once?
A21. No modifier is needed for the initial codes of E/M, AWV, IPPE or G0506 code. There is no minimum time requirement listed in the HCPCS manual; however, Medicare would expect a reasonable amount of time to support the need for this add on code and only billed once per patient.
Q22. Can time count when a pharmacy calls to say medications are no longer allowed/available and our office has to figure out what other medication can be prescribed?
A22. Yes, this is part of the medication management and the physician needs to determine which drug would be comparable.
Q23. Can providers still bill CCM if our practice does not have Electronic Health Records (EHRs)? Can you provide information needed regarding an EHR?
A23. CMS reduced the technology requirements for certified EHR (limited data set) and changed their focus to timely exchange of health information (care plan and transitional care document(s)), rather than specific electronic technology for these pieces. The care plan no longer has to be available electronically to individuals providing CCM after hours, as long as they have timely information.
CMS does not require practitioners to use a specific tool or service to communicate clinical summaries in managing care transitions, as long as practitioners transmit the clinical summaries electronically, with the exception of faxing. We are clarifying that a practitioner may satisfy the CCM scope of service element around transitions of care if the practitioner electronically transmits a summary to a third party provider, and this summary of care is then transmitted to the receiving practitioner/provider through another method, including fax. This policy is consistent with guidance that CMS has previously issued with regards to meeting the transitions of care objectives within the EHR Incentive Programs, available at https://questions.cms.gov/faq.php?faqId=10660 .
Regarding the requirement to electronically transmit care plan information other than by fax, we expect that some practitioners may transmit care plan information as part of the structured clinical summary. We remind practitioners that alternative secure methods of sending electronically such as HIPAA compliant encrypted email are also acceptable. However, in those instances where the receiving practitioner/provider (who is not billing for CCM) is only able to receive care plan information electronically by fax, the care plan information may be directly transmitted via fax.
Practitioners must use technology certified to the Edition(s) of certification criteria that is acceptable for the EHR Incentive Programs as of December 31st of the year preceding each CCM payment year. In certain years, this may mean that practitioners can fulfill the scope of services requirement using multiple Editions of certification criteria.
This remains true for a given physician fee schedule (PFS) payment year even after Office of National Coordinator for Health Information Technology (ONC) and the Authorized Certification Bodies (ONC-ACBs) have removed the certifications issued to technology certified to a given acceptable edition (e.g., the 2011 Edition for CCM payment in 2015). This was as a result of the relevant criteria being removed from the Code of Federal Regulations (CFRs). Thus, practitioners using an acceptable EHR technology that loses its certification mid-year may still use that technology to fulfill the certified EHR criteria for billing during the applicable payment year.
CMS continues to encourage and support the use of certified technology and increased inter-operability and transition to advanced electronic technologies, due to incentives of the Quality Payment Program, independent of CCM rules.
Last Updated Mar 17, 2017