Chronic Care Management in Post-Acute/LTC Setting

Society for Post-Acute and Long-Term Care Medicine Annual ConferenceWednesday, March 16, 2016

Chronic Care Management in a Post-Acute Care World

A Post-Acute Care World

The Current Healthcare Environment

Prepared for The Society for Post-Acute and Long-Term Care Medicine Page 3

The Current Healthcare Environment

Sick Patient

Acute Care

Post-Acute Care

Sick Patient

Chronic Care

Home

Consta

nt CCM

Inter

actio

n

HAC Penalties

Value-

Based

Purchasing

Chronic Care = Acute

Exacerbation

Readmission Penalties

Medical Necessity Denials

Increased Inpatient Cost

Two

Midnight

Rule

Quality Measures


Fast Facts

Source: https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx, (March 10, 2016).

https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx


Fast Facts

Source: https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx, (March 10, 2016).

https://www.ahcancal.org/research_data/trends_statistics/Pages/Fast-Facts.aspx


Reimbursement Differences

Traditional PAC Professional Services National average non-

facility reimbursements: CPT 99305 - $131.401

CPT 99308 - $69.821

Chronic Care Management Services National average non-

facility additional reimbursement per beneficiary per month: $40.822

1) Centers for Medicare & Medicaid Services, “Physician Fee Schedule” (March 10, 2016). www.cms.gov/apps/physician-fee-schedule2) Centers for Medicare & Medicaid Services, “Physician Fee Schedule” (March 11, 2016). www.cms.gov/apps/physician-fee-schedule

http://www.cms.gov/apps/physician-fee-schedule/search

http://www.cms.gov/apps/physician-fee-schedule/search


Potential CCM Gross Annual RevenueDescription Low Range High Range Formula

Annual Number of Unique Patients1 1,742 1,742 A

Percent of Patients Covered by Medicare1 29.12% 29.12% B

Annual Number of Unique Medicare Patients 507 507 C = A*B, Rounded

Percent Qualifying for CCM2 34.3% 68.6% D

Annual Number of Unique CCM Patients 174 348 E = D*C, Rounded

Average Annual Months to Bill per Patient3 6 12 F

CCM Monthly Payment4 $40.82 $40.82 G

Annual Gross Revenue for Family Medicine Physician $42,658 $170,464 H = (G*F)*E1 Per the MGMA Cost and Revenue Survey: 2015 Report Based on 2014 Data specific to the specialty of family medicine (median results). Includes traditional and Medicare Advantage.2 CMS.gov - County Level Multiple Chronic Conditions (MCC) Table: 2012 Prevalence, National Average is 68.60% (our upper end). Low range is based on 20% less than the average.3 Based on The National CCM Survey 2015, three-quarters of respondents believed that patients would be eligible for CCM services for 6 months or less during a calendar year. Low- and high-end ranges consider this response.4 Reimbursement amount from the CY 2015 Physician Fee Service Final Rule; assumes 100% of unique patients are covered via traditional reimbursement. Medicare Advantage reimbursement may vary.

What Is Chronic Care Management?

A Working Definition


CCM Components At least 20 minutes of clinical staff time, directed by a

physician or other qualified healthcare professional, per calendar month: Multiple (two or more) chronic conditions expected to last at least 12

months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute

exacerbation/decompensation, or functional decline Comprehensive care plan established, implemented, revised, or

monitored


Qualifications Furnished by clinical staff

Delegating physician determines individual is qualified Permissible under state law Non-clinical staff administrative time does not count

Under physician/non-physician general supervision Vs. usual direct supervision requirement for “incident to” billing No physical presence requirement Supervisor does not have to be billing provider


Asynchronous Exception Monitoring

“Practitioners who engage in remote monitoring of patient physiological data of eligible beneficiaries may count the

time they spending reviewing the reported data towards the monthly minimum time for billing the CCM code, but

cannot include the entire time the beneficiary spends under monitoring or wearing a monitoring device.”

Source: Centers for Medicare & Medicaid Services, “Frequently Asked Questions about Billing Medicare for Chronic Care Management Services” at 5 (May 7, 2015). http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/Payment-Chronic-Care-Management-Services-FAQs.pdf .

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/Payment-Chronic-Care-Management-Services-FAQs.pdf


Warning: 20+ Minutes 20+ minutes non-face-to-face care management services

per calendar month 20 minutes can be aggregated, but not rounded up May be provided by different individuals, but cannot count

double for two staff members providing services at the same time


Warning: No “Double Dipping” Cannot bill for CCM and any of the following during same

30-day period: Transitional care management (99495 and 99496) Home healthcare supervision (G0181) Hospice care supervision (G0182) ESRD services (90951-90970)

CMS will not pay for more than one provider to furnish CCM in each calendar month


Key Considerations1. Eligible providers2. Eligible beneficiaries3. Consent to receive CCM4. Five specific capabilities5. Non-face-to-face services


1. Eligible Providers Physician (any specialty), APRN, PA, CNS,CNMW Not an RHC/FQHC service No qualifying services (e.g., annual wellness visit)

However, must be initiated with face-to-face visit No practice accreditation (e.g., PCMH)


2. Eligible Beneficiaries 2+ chronic conditions

No definitive list – CMS maintains the Chronic Condition Warehouse3 (CCW) for approximately 60 specified chronic and potentially disabling conditions, but this is not an exclusive list and CMS may recognize other conditions

Expected to last at least 12 months, or until the death of the patient; place patient at significant risk of death, acute exacerbation/decompensation, or functional decline

3) https://ccwdata.org/web/guest/condition-categories

https://ccwdata.org/web/guest/condition-categories


3. Written Consent Provider cannot bill for CCM unless and until it secures

beneficiary’s written consent Consent must be obtained during or after face-to-face

visit If beneficiary revokes consent, cannot bill for CCM after

then-current calendar month Must be documented in certified EHR (see below)


4. Five Specified Capabilities Provider must demonstrate following capabilities:

A. Use of certified EHR for specified purposesB. Electronic care planC. Beneficiary access to careD. Transitions of careE. Coordination of care

Submission of claim = attestation of capabilities


A. Use of Certified EHR Must utilize “CCM-certified technology” for specified

purposes in providing CCM the edition(s) of the meaningful use certification criteria in use as

of 12/31 of preceding year Not required to be meaningful user of certified EHR

technology


B. Electronic Care Plan Maintain regularly updated electronic care plan for

beneficiary Based on physical, mental, cognitive, psychosocial, functional,

and environmental (re)assessment of beneficiary’s needs Inventory of resources and supports Addresses all health issues (not just chronic conditions) Congruent with beneficiary’s choices and values

Preparation and updating of care plan is not a component of CCM; may bill as separate E&M code if requirements satisfied (e.g., AWV)


Access to Electronic Care Plan1. Electronically accessible 24/7 to all care team members

furnishing CCM services billed by the practice E.g., remote access to EHR, web-based access to care

management application, web-based access to HIE – not facsimile

2. “Must electronically share care plan information as appropriate with other providers” caring for patient

E.g., secure messaging, participation in HIE – not facsimile

3. Provide paper or electronic copy to beneficiary Must be documented in certified EHR


C. Beneficiary Access to Care 1. Means for beneficiary to access provider in the practice* on

24/7 basis to address acute/urgent needs in timely manner2. Beneficiary’s ability to get successive routine appointments

with designated practitioner or member of care team3. Enhanced opportunities for beneficiary-provider (or caregiver-

provider) communication by telephone + asynchronous consultation methods (e.g., secure messaging, internet)

*person whose time is counted in 20 minutes of non-face-to-face care management services per month


D. Transitions of Care Capability and capacity to do the following:

Follow up after ER visit Provide transitional care management Coordinate referrals to other clinicians Share information electronically with other clinicians as

appropriate Summary care record and electronic care plan No specific manner of transmission required


E. Coordination of Care Coordinate with home- and community-based clinical

service providers to meet beneficiary’s psychosocial needs and functional deficits Home health and hospice Outpatient therapies DME suppliers Transportation services Nutrition services

Communications with these providers must be documented in certified EHR


5. Non-Face-to-Face Services Types of service (non-exclusive)

Performing medication reconciliation, oversight of beneficiary self-management of medications

Ensuring receipt of all recommended preventive services Monitoring beneficiary’s condition (physical, mental, social)

Documentation Date and time (start/stop?) Person furnishing services (with credentials) Brief description of services


Billing Rules Date of service = day on which meet 20 minute

requirement (or any day thereafter thru end of month) May bill after date of patient’s death, but only if met 20-minute

requirement prior to that date Site of service = location at which billing practitioner

normally would see patient for face-to-face visit

Adding Chronic Care Management

Chronic Care Management Options


Creation and Operations Opportunities for partnership (physicians, health systems) Impact on relationship with referring physicians Legal structure Regulatory compliance issues Billing Marketing implications Operationalizing impacts Hiring vs. contracting supervising MD, impact on

relationships with current physicians and staff


Option 1 for Delivering CCM HHA/SNF-employed Qualified Provider (QP) performs QP-required

elements of service with HHA/SNF staff performing other elements: HHA/SNF must have Part B billing number (HHA/SNF = Part A) QP may be part-time employment limited to CCM services QP reassigns billing rights to HHA/SNF; HHA/SNF submits claim to Part

B; HHA/SNF responsible for maintaining documentation Structure arrangement to satisfy Stark Law except, Anti-Kickback Statute

safe harbor Not permitted in states prohibiting corporate practice of medicine


Option 2 for Delivering CCM HHA/SNF-contracted QP performs QP-required elements of service

with HHA/SNF staff performing other elements: HHA/SNF must have Part B billing number (HHA/SNF – Part A) Contract may be with individual QP or physician practice Scope of contract may be limited to CCM services QP reassigns billing rights to HHA/SNF; HHA/SNF submits claim;

HHA/SNF responsible for maintaining documentation Structure arrangement to satisfy Stark Law except, Anti-Kickback Statute

safe harbor Fair market value for QP payments based on wRVU analysis Option in states prohibiting corporate practice of medicine


Option 3 for Delivering CCM Independent individual QP or physician practice contracts with

HHA/SNF to provide non-QP-required elements: Option for QP/practice that lacks staff and/or infrastructure to provide

support services QP/practice pays HHA/SNF flat rate or per-service rate (based on wRVU

analysis) Structure arrangement to satisfy Stark Law except, Anti-Kickback Statute

safe harbor QP/practice submits claim; QP/practice responsible for maintaining

documentation


Option 4 for Delivering CCM Hospital/SNF/community mental health center with partial

hospitalization program contracts with HHA/SNF to provide non-QP required elements: Option for facility that wants to use its employed/contracted QPs to

furnish CCM services, but lacks staff and/or infrastructure to provide support services

QP/practice pays HHA/SNF flat rate or per-service rate (based on wRVU analysis)

Structure arrangement to satisfy Stark Law except, Anti-Kickback Statute safe harbor

Facility submits claim (based on reassignment from QP/practice); facility responsible for maintaining documentation


Option 5 for Delivering CCM ACO contracts with HHA/SNF to coordinate its CCM program and/or

provide non-QP required elements: Option for ACO that wants to support participating physicians who lack

staff and/or required infrastructure to provide support services ACO pays HHA/SNF flat rate or per-service rate (based on wRVU

analysis) ACO-participating physicians submit claims and responsible for

maintaining documentation


Questions

PERSHING YOAKLEY & ASSOCIATES, P.C.800.270.9629 | www.pyapc.com

Denise HallPrincipal

[email protected]

Lori BakerManager

[email protected]

mailto:[email protected]

mailto:[email protected]