1. Whose time counts towards the 20 minute requirement?
Aside from physicians and non-physician practitioners, such as Nurse Practitioners, Physicians Assistants, Certified Nurse Midwives, Clinical Nurse Specialists, services provided by clinical staff incident to the physician or billing practitioner count towards the 20 minute requirement as well. While there is some variation on a state by state basis, time spent by the following clinical staff members typically counts towards the 20 minute requirement: Registered Nurses, Licensed Practical Nurses, Licensed Clinical Social Workers, Certified Medical Assistants, and Certified Nurse Assistants. Non-clinical staff time cannot be counted. TimeDoc can help you determine which staff members’ time counts.
2. What activities count towards the 20 minute requirement?
Any non-face-to-face care management and coordination service provided on behalf of an enrolled beneficiary by a clinical staff member or provider counts. Here are a few of the activities that count:
- Phone calls, emails, and messaging with the patient and their caregiver and family members
- Lab, report, and image review and processing
- Care plan creation, revision, and review
- Chart documentation
- Medication reconciliation, overseeing patient self-management of medication
- Medication refills
- Referring to and consulting with other providers and time spent closing the referral loop
- Communicating with home and community-based providers
- Remote monitoring of physiological data
- Post-discharge follow-up
- Physicians and clinical staff members have always spent a significant amount of time on these activities, but have not been reimbursed for them, until now.
3. Is reimbursement higher if I spend more than 20 minutes on a patient?
Not yet. However, beginning in 2017 there will be two new codes for “complex” CCM services in addition to 99490:
✓ 99487: 60 minutes of clinical staff time per calendar month
✓ 99489: Additional 30 minutes of clinical staff time per calendar month
4. What insurance plans will pay this code?
Medicare and Medicare Advantage plans. We understand that commercial plans are evaluating now and plan to accept it soon. In terms of contracts, Fee-For-Service (FFS) contracts are eligible, but capitated contracts do not cover 99490 at this time (although the CMS ruling stated they will evaluate it).
5. Is there a list of chronic conditions to deem which patients are eligible?
CMS has stated they have left the ruling open to discernment by the provider, i.e. CMS has not provided a definitive list of chronic conditions that count for CCM. Instead, they have referenced the Chronic Condition Warehouse as a good starting point.
6. Are patients residing in a facility setting eligible to be billed for CCM?
CMS has stated in the final rule that physicians cannot bill CCM services for patients in a facility setting. CMS said, “The resources required to provide care management services to patients residing in facility settings significantly overlaps with care management activities by facility staff that is included in the associated facility payment.” CMS did not define “facility” beyond that. We interpret “facility” in this context to be any health care entity (e.g., hospital, skilled nursing facility, etc.) that receives a facility payment from Medicare. If an assisted living facility is receiving Medicare facility payments for a given patient residing in that facility, we do not believe that you can report CCM for that patient.
7. Are patients responsible for any portion of the CCM fee?
The same as any other billable code, the patient is responsible for deductibles, copayments, and remainder amounts according to the patient’s insurance agreement. For 99490, patients are responsible for a 20% copayment which comes out to about $8/month. However, we’ve seen that 65-85% of Medicare Part B patients have a secondary Medigap plan that will cover the copayment. Some Medicare Advantage plans cover the copayment as well.
8. What if a patient asks, “Why am I getting charged for services you have been providing for free for years?”. How do I explain the value of this program to my patients?
The whole team, from the front desk to the providers, must be educated on CCM so that they can articulate the value of the program to patients. Here are some talking points that can help you explain CCM to patients:
- The intent of CCM is to reduce costs for all parties, including the patient, by preventing problems before they arise and keeping patients healthy, at home. Greater access to the care team and better coordination means fewer visits to the hospital, which in turn reduces the patient’s overall out-of-pocket expenses.
- Medicare is starting to recognize all of the work that physicians and care teams have been providing for years and this program allows your practice to continue providing the high level of care your patients need.
- Health care is changing and Medicare is increasingly moving reimbursement towards value-based programs like CCM. This is one of the first steps towards the new system that rewards doctors for preventing problems and keeping patients healthier.
9. Can a patient enroll in CCM with multiple providers? If not, what happens when they do?
Only one provider may bill CCM in a given month, so patients should only enroll with one provider. At the time of enrollment, you should ask the patient whether they have enrolled in CCM with another provider. The patient might not know – in that case, you will find out whether they have enrolled with someone else when you attempt to bill that patient. Medicare will accept the claim for whomever bills the patient first. Alternatively, the other provider might reach out to you to share the patient’s CCM care plan, in effect notifying you that they have enrolled that patient.
10. A patient has consented to receive CCM services, do CCM services have to be provided every month, even if no follow-up or additional assistance is appropriate?
No. While the goal of CCM is to increase continuity of care to prevent health issues from arising, you are not required to provide the full scope of services each month. The consent for receiving CCM services remains in effect until revoked, even if no CCM services are furnished.
11. Is there a time when a patient covered by CCM is not eligible for the service?
In any given calendar month, patients cannot be billed for CCM if they are being billed for one of the following codes:
- Transitional Care Management (99495-99496)
- Home Healthcare and Hospice Care Supervision (G0181, G0182)
- Certain End-Stage Renal Disease codes (90951-90970)
TimeDoc works with your biller to ensure that CCM is not being billed with one of these overlapping codes.
12. How will my biller know when a patient has achieved 20 minutes of CCM services and is billable?
TimeDoc software tracks CCM time per patient and creates a billing report at the end of each month listing every patient that has achieved 20 minutes. The report is automatically sent to your biller and includes the information needed to create claims for Medicare. TimeDoc works directly with your in-house or third party billing team to establish a workflow.
13. How can we collect the payment that the patient is responsible for if this is a non-face-to-face service?
There are a few strategies for collecting copayments for patients without a secondary health plan, including credit-card-on-file and charging a patient at the time of their next in-person visit.
14. How can my practice be prepared in case of a Medicare audit?
Documenting CCM services and the time spent on them to prove that 20 minutes were provided per patient per month is critical to withstanding a Medicare audit. TimeDoc integrates with your EHR to enable time tracking and maintain an audit trail of CCM services provided. Further, you must ensure that a robust CCM care plan is created, maintained, and shared with the patient and appropriate members of the patient’s care team. TimeDoc CCM software helps with these care plan requirements as well.
15. Is TimeDoc technology HIPAA-compliant?
Of course! We pay a premium for HIPAA and HITECH-certified hosting of our data. Everyone on the TimeDoc team follows appropriate HIPAA protocols and procedures as well.
16. How long does it take for TimeDoc to implement the software at our practice?
We can move as quickly as you want us to. We have to work with the practice’s IT System Administrator to get the appropriate access so that we can turn our solution on, but there isn’t much work other than that! We conduct on-site or online training depending on the preference of the practice.
17. Are FQHCs and RHCs eligible for CCM?
Yes. Beginning on January 1, 2016, FQHCs and RHCs may receive payment for CCM services. Requirements are very similar to the general CCM requirements, and are exactly the same regarding patient eligibility, patient consent, and the scope of services for chronic care management.
Centers for Medicare & Medicaid Services has published a Frequently Asked Questions (FAQ) document that is solely devoted to FQHCs and RHCs. The document can be found here.
18. What are the differences for FQHCs and RHCs compared to other organizations?
There are several relevant differences that we have noted below:
- Clinical staff members providing CCM services are subject to direct supervision by the billing practitioner for FQHCs and RHCs. This means that an FQHC/RHC practitioner needs to be present in the FQHC/RHC and immediately available to furnish assistance and direction. However, they do not need to be present in the same room when the service is furnished.
- Telephone calls and other CCM services can be done in a location other than the FQHC/RHC, but these services would be subject to the direct supervision requirements.
- Beginning in 2017, general supervision is allowed for FQHCs and RHCs. FQHCs and RHCs will be able to use CCM vendors to complete the scope of services.
- The payment rate in 2016 for CCM services in FQHCs and RHCs is $40.82. This rate is not geographically adjusted.