Complex chronic care management—more money or more headaches?

Managing chronic conditions is both time- and resource-intensive for physicians, many of whom spend countless hours coordinating care outside of a typical patient visit. Physicians are not currently reimbursed for this time; however, this policy changed when CMS recently finalized its proposal to make a separate payment for non-face-to-face chronic care management (CCM) for Medicare beneficiaries who have multiple (i.e., two or more) significant chronic conditions.

The calendar year 2015 Medicare Physician Fee Schedule final rule was published as a display copy on Friday, October 31, 2014. In it, CMS states it will pay for non-face-to-face chronic care management services, including ongoing development and revisions of care plans, communication with other treating providers, and medication management.

In its final rule, CMS outlines the following points related to chronic care management:

• CMS will allow approximately $42 for code 99490 that denotes non-face-to-face CCM. Patients must have two or more chronic conditions that are expected to last at least 12 months or until the patient’s death and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
• To bill this code, physicians or their clinical staff members must spend at least 20 minutes performing the CCM services. Direct supervision is not required, which means that nursing staff or non-physician practitioners can render CCM even if the physician is not in the office.
• Physicians may bill this code no more frequently than once per month per qualified patient.
• For CCM payment in 2015, physicians must use EHR technology certified to either the 2011 or 2014 edition(s) of certification criteria.

“We see [CCM] as a step in the right direction,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians (AAFP). “Ideally, we’d like to see a risk-adjusted care management fee on a per-member-per-month basis rather than something that has to be billed on a fee-for-service basis … but we applaud CMS for moving in this direction.”

In its final rule, CMS states it is “committed to supporting primary care” and that it “increasingly recognized care management as one of the critical components of primary care that contributes to better health for individuals and reduced expenditure growth.”

Although primary care physicians may be the ones who report CCM most often, it seems clear that they will not be the only physicians to use these codes, says Moore. “As I read the CMS policy, it seems to be their intent that this is aimed at primary care physicians, but there’s nothing in the policy that limits it to primary care,” he adds.

Still, the laundry list of requirements with which physicians must comply may be a barrier for some, regardless of specialty. The following are only some of these requirements:

• Ongoing patient access to the practice. This includes access 24 hours a day, 7 days a week.
• Continuity of care, which means that patients should be able to get successive routine appointments with a designated practitioner or member of the care team.
• Systematic assessments of patients’ medical, functional, and psychological needs. This includes timely preventive care services, medication reconciliation, and oversight of patients’ ability to self-manage medications.
• Creation of a patient-centered care plan document that serves as a comprehensive plan of care for all health issues.
• Management of patients’ care transitions among providers and settings.
• Enhanced opportunities for a beneficiary and/or caregiver to communicate with practitioners via phone, secure messaging, Internet, or other asynchronous methods.
  ​

In its comments to CMS regarding the proposed rule, the AAFP pointed out several other questions and concerns regarding CCM. For example, CMS plans to pay for only 20 minutes of clinical staff time as part of performing these services.

“Anybody who performs more than 20 minutes of clinical labor time will be underpaid,” says Moore. “From that perspective, we’re not satisfied with the value based on the description of the code. Patients with multiple chronic conditions may take significantly more time and resources.”

The AAFP urges CMS to include more than 20 minutes of clinical staff time in the direct practice expense inputs for the code. The Academy says that 60 minutes would be more appropriate. It also suggests unbundling CPT codes 99487 and 99489, which allow for add-on codes to capture additional time spent.

Moore says the EHR requirement may be a “major barrier” to widespread use of the proposed CCM code. In its comments to CMS, the AAFP says that family physicians who have not adopted an electronic record are more than capable of managing patients’ chronic conditions.

However, CMS states that the EHR requirement will actually help practices perform CCM services and avoid overburdening small practices in particular. The agency states the following: “We indicated that we believed that allowing flexibility as to how practitioners capture, update, and share care plan information was important at this stage given the maturity of current EHR standards and other electronic tools in use in the market today for care planning.”

Tracking CCM may also be problematic for physicians. “The practice is going to need some way to keep track of how much clinical staff time is spent to ensure that it does, in fact, reach the 20-minute threshold,” says Moore. This may be difficult when services are rendered throughout the month in small increments. It may also be challenging to configure the billing or practice management system to hold claims so that these services are only billed once per month. Moore says the AAFP is developing an Excel tool to help practices track time spent on CCM.

In addition, CMS has not published a list of diagnoses for which CCM can be rendered (i.e., eligible chronic conditions that meet the definition of the code). “Whether or not the absence of such a list will help or hurt physicians as they take advantage of this code remains to be seen,” says Moore.