CMS Chronic Care Management Medicare Reimbursement: Sizeable Revenue, Health Outcome Opportunities

Friday, November 21st, 2014
This post was written by Cheryl Miller

Beginning January 2015, Medicare will pay a flat, monthly chronic care management (CCM) fee to providers coordinating care for beneficiaries with more than one chronic condition. This change will expand the current Medicare payment policy to include non face-to-face management services previously included within payments for evaluation and management (EM) services, amount to about $40 a beneficiary, a sizeable new source of revenue for eligible providers.

The targeted population is also substantial; as recent news story reported by the Healthcare Intelligence Network (HIN), 87 percent of U.S. adults ages 65 and older have at least one chronic illness, and 68 percent have two or more, the highest rates in a new 11-country Commonwealth Fund survey.

But healthcare organizations do not have that much time to prepare for the newly released 2015 Medicare Physician Fee schedule, which finalized the CCM reimbursement. Who can bill for CCM, what constitutes a chronic condition, which patients are eligible to receive CCM services, and the scope of services required were among the issues discussed during Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care Coordination, a November 19th webinar, now available for replay. Rick Hindmand, an attorney with McDonald Hopkins, a law firm that advises a nationwide client base extensively on healthcare reimbursement, shared insight on these issues and how to best prepare for this reimbursement opportunity.

Those allowed to bill for CCM reimbursement fall into one of five categories: physicians, advanced practice registered nurses (APRNs), physician assistants (PAs), clinical nurse specialists and certified nurse midwives. If these practitioners are part of a practice entity, that entity can bill for it as well.

Beneficiary requirements are not as clear cut, Mr. Hindman continued. Eligible patients must have at least two chronic conditions that are expected to last at least 12 months or until death, and those conditions need to create a significant risk of death, acute exacerbation/decomposition or functional decline. Specific definitions of conditions can be found at CMS’s Web site.

And because CMS does not want to pay for duplicative services, CCM is not allowed for beneficiaries who receive services for transitional care management, home healthcare supervision, hospice supervision, and various end stage renal disease (ESRD) conditions. Patients attributed under the Multi-payer Advanced Primary Care Practice Demonstration (MAPCP) and the Comprehensive Primary Care (CPC) Initiative are also excluded.

Once these requirements are satisfied, providers must offer and document 20 minutes of CCM services a month, which enhance access and continuity of care, care management, transition management, and coordination, Mr. Hindman continues.

The CCM fee comes to about $40 a beneficiary, a significant revenue source once applied to all patients within a practice. Why the change now? Mr. Hindman speculates that CMS is finally realizing that care management is a crucial component of primary care. But questions and details await future guidance from CMS, and satisfying and documenting compliance with the CCM reimbursement requirements is going to present a challenge for many practices.

But the time and effort is worth it, he says. “With careful structuring, chronic care management can provide the potential to improve the health of their patients, while also providing some significant financial benefits for the practice.”

To listen to an interview with Mr. Hindman, click here.

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