Chronic Care Management FAQ
In 2015, CMS began reimbursing healthcare providers for chronic care services provided to qualifying Medicare patients.
Now, with help from Wellbox, you can get paid for the ongoing care you provide to your Medicare patients with chronic conditions, without interrupting your current workflow.
The Wellbox Chronic Care Management program provides an all-inclusive method for providing, tracking and billing CCM services.
PRACTICE & PATIENTS
Who is an eligible beneficiary?
A beneficiary is eligible to receive CCM if he or she has been diagnosed with two or more chronic conditions* expected to persist at least 12 months (or until death) that place the individual at significant risk of death, acute exacerbation/decompensation, or functional decline.
Is there a list of chronic conditions that qualify under the program?*
CMS maintains a Chronic Condition Warehouse (CCW) to provide researchers with beneficiary, claims and assessment data linked by beneficiary across the continuum of care. The CCW includes 22 specified chronic conditions:
- Acquired Hypothyroidism
- Acute Myocardial Infarction
- Alzheimer’s Disease & Related Disorders
- Atrial Fibrillation
- Benign Prostatic Hyperplasia
- Cancer, Colorectal
- Cancer, Endometrial
- Cancer, Breast
- Cancer, Lung
- Cancer, Prostate
- Chronic Kidney Disease
- Chronic Obstructive Pulmonary Disease
- Heart Failure
- Hip/Pelvic Fracture
- Ischemic Heart Disease
- Rheumatoid Arthritis
- Stroke/Transient Ischemic Attack
* This is not an exclusive list of chronic conditions. CMS may recognize other conditions for purposes of providing CCM.
What type of service qualifies for reimbursement?
CMS specifies that the code 99490 must be billed for 20 minutes of “non-face-to-face time follow-up care outside the office” each month, with code 99487 being for 60 minutes of complex care provided. This includes charting and scheduling for virtual office visits.
The Wellbox CCM program integrates patient scheduling for virtual visits; charting their encounter and prescribing and are the same workflows as the ones you use to record a standard office visit.
Is a practice required to be recognized as a patient-centered medical home (PCMH) to provide CCM?
CMS had proposed patient-centered medical home (PCMH) recognition as a condition for billing under chronic care management coding, but the Final Rule does not include that requirement.
Are there services a provider must furnish to a beneficiary prior to billing for CCM for that beneficiary?
While CMS strongly recommends that a provider furnish an Annual Wellness Visit (HCPCS G0438, G0439) or an initial preventive physical exam (G0402) to the beneficiary, there are no prerequisite services to bill for CCM.
How long will the reimbursements last?
We anticipate CCM being around for years to come. All signs point to CMS expanding the program. In fact, CMS has launched an initiative to promote CCM, as they deem it to be a critical component to primary care.
Are Medicare Advantage Plans covering 99490 and 99487?
Medicare advantage plans vary from state to state and are inconsistent at best.
Will Medicare Advantage (MA) Plans reimburse for CCM?
A Medicare Advantage plan is required to offer its enrollees at least traditional Medicare benefits, which will now include CCM. However, MA plans are inconsistent in reimbursing for 99490 and 99487.
What type of consent is required?
A provider cannot bill for CCM unless and until the provider secures the beneficiary’s verbal consent.
What additional costs are involved for the patient?
Since CCM is not classified as a preventive service, patients without Medicare Part B and supplemental insurance will have a co-pay of approximately $8. About 90% of your patients may not have to pay out of pocket for the co-pay. Only one in 10 beneficiaries rely solely on the Medicare program for health care coverage. The rest have some form of supplemental coverage to help with medical expenses.
What is needed to comply with the Beneficiary Agreement requirement?
- Inform the beneficiary about the availability of CCM services from the practitioner and obtain his or her verbal agreement to have the services provided.
- Document in the beneficiary’s medical record that all elements of the CCM service were explained and offered to the beneficiary, and note the beneficiary’s decision to accept or decline the service.
- Provide the beneficiary a written or electronic copy of the care plan and document in the electronic medical record that the care plan was provided to the beneficiary.
- Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of a calendar month) and the effect of a revocation of the agreement to receive CCM services.
- Inform the beneficiary that only one practitioner can furnish and be paid for these services during the calendar month service period.
- Advise the beneficiary of their cost sharing obligation.
What level of resources and automation is required to comply with the Transitions of Care requirement?
Transitions of Care include electronic referrals to other clinicians, follow-up after the patient’s visit to an emergency department, and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities. The practice must also have qualified personnel who are available to deliver transitional care services to the patient in a timely manner so as to reduce the need for repeat visits to emergency departments and readmissions to hospitals, skilled nursing facilities or other health care facilities.
Is there a required communication tool or format for the Transition of Care requirement to share clinical summary care records?
The electronic care plan must be furnished using an EHR or other health IT or health information exchange platform (other than facsimile transmission), to all practitioners within the practice, including outside of normal business hours, and with care team members outside of the practice. Practitioners “within the practice,” means any practitioners furnishing CCM services whose minutes count towards a given practice’s time requirement for reporting the CCM billing code. This was done to allow practitioners to innovate around the systems that they use to furnish these services, and avoid overburdening small practices.
Can I be reimbursed for remote patient monitoring expenses (e.g., if prescribed for self-monitoring)?
Chronic Care Management is defined as non face-to-face services; therefore, they are not included as a requirement for home or domiciliary visits or community based care. Yet, practitioners who engage in remote monitoring of patient physiological data of eligible beneficiaries may count the time they spend 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.
How will CCM help with MACRA/MIPS?
Chronic Care Management (CCM) programs such as Wellbox help physicians and practices achieve high performance scores and get reimbursed for the care they provide. Through such programs, MIPS categories can easily be satisfied: Quality Measures, Advancing Care Information (MU), Clinical Practice Improvement Activities (CPIAs).
If I hire someone can I do it myself?
Yes, but many providers find it is more advantageous economically to partner with us. We have found that many practices don’t have the time or the money to take on the entire program alone.
Is it legal to outsource the service?
Absolutely, CMS states this in the CCM guidelines. The physician’s practice reviews all of the notes and we act as an extension of your practice.
Who does the actual calling?
The care is coordinated between RNs and CCPs, generally we have a CCP making the outreach efforts and then provide care accordingly.
What is needed to comply with the Beneficiary Agreement requirement?
- Practitioner-to-beneficiary secure text messaging for non-face-to-face consultation methods;
- Real-time management of monthly invested and remaining CCM beneficiary consulting time;
- Auditable tracking of time invested per patient to reduce risk of failing a RAC audit;
- Patient appointment management (request, cancel, change, pre-registration, eCheck-In);
- EMR/EHR/portal-agnostic electronic exchange, enabling CCM-required document sharing and cross-continuum care coordination;
- Electronic referral management between participating providers;
- Beneficiary consent and attestation templates.
How do you document?
We document the visit as an encounter directly in your EHR. During the kick-off call we work with the practice to mirror your currently workflow as closely as possible.
How can patients sign up?
We take the time to educate your patients on the service and obtain verbal consent before starting the program.
How do we know what patients to bill for?
Once the encounter is completed, it is transferred to the provider for review. Wellbox then provides a monthly list that can be used for reconciliation purposes.
How much is a doctor’s total reimbursement?
The national reimbursement average for Chronic Care Management services under code 99490 is $43 per patient per month. Under the code 99487 for complex CCM, the average reimbursement is $94 for 60 minutes of non-face-to-face care. Reimbursements vary depending on location, which can be found on the CMS website. We can help look that up for you.
Chronic Care Management Changes - CMS Source
What kind of certifications do the CCCs have?
All of our CCCs are Registered Nurses. We also have a special training program they complete before providing remote care – Chronic Care Professional (CCP).
Where is the call center?
The call center is located in Jacksonville, Florida.
What is the level of involvement for doctors when outsourcing?
All the doctor needs to do is review the notes and sign off on the encounters, as well as submit the superbill.
Who’s responsible if the call center makes a mistake?
We take all steps necessary to ensure we follow all the requirements set by Medicare. We record calls for quality assurance and have quality control measures and a great management team in place to limit the risk of mistakes. We stand behind all of our work. We must let you know that you are signing off on all of the notes so there is responsibility on the practice as well.
Do they need any new hardware/software installed to do this?
In most cases, no. We will however, need a username and password for logging into your EHR.
Are there any hidden fees at all?
How much do we do for the patient on their medical encounter form? (i.e.: meds, allergies...)?
Prior to start, we go through an intricate questionnaire with your office and determine what you would like us to help with.
Can a provider bill for other services during the same month as CCM?
If a provider furnishing CCM performs any other services for the beneficiary (such as an office visit or an immunization), the provider should bill for that service in addition to CCM.
Can more than one provider bill for Chronic Care Management services with either CPT code 99490 or 99487?
The code can only be billed by one provider per patient, for Medicare patients who have two or more chronic conditions for code 99490 and for patients who meet all requirements to fall under code 99487.
Which providers can bill Medicare for CCM?
- Physicians (regardless of specialty)
- Advanced Practice Registered Nurses
- Physician Assistants
- Clinical Nurse Specialists
Which providers are not eligible to bill Medicare for CCM?
Other non-physician practitioners and limited-license practitioners (e.g., clinical psychologists, social workers).
Are there services for which a provider is not allowed to bill during the same calendar month as CCM?
- Transitional care management (CPT 99495 and 99496)
- Home healthcare supervision (HCPCS G0181)
- Hospice care supervision (HCPCS G0182)
- Certain end-stage renal disease (ESRD) services (CPT 90951- 90970)
What level of professional can bill for the 20 minutes of non-face-to-face time?
Eligible practitioners must act within their State licensure, scope of practice and Medicare statutory benefit. Services provided directly by an appropriate physician or non-physician practitioner, or other clinical staff “incident to” the billing physician practitioner, counts toward the minimum service time required to bill for CCM services per calendar month.
Non-clinical staff time cannot be counted towards the minimum CCM monthly services; however, CCM services may be recorded by non-clinical staff.
What is the level of “incident to” practitioner supervision required to bill for CCM services?
The time spent by clinical staff, irrespective of the nature of the employment or contractual relationship between the clinical staff and the practitioner or practice, providing aspects of CCM services can be counted toward the CCM time requirement at any time. This is provided that the clinical staff are under general supervision of the practitioner and all other elements of the services and supplies incident to a physician’s professional services regulations are met.
How do we bill?
Submit a CMS 5010 form to Medicare with a 99490 CPT code or 99487 CPT code and the 2 chronic DX codes on it.
What requirements are needed for a patient to fall under CPT code 99487 for complex CCM?
A patient is deemed complex and eligible for 60 minutes of non-face-to-face care when they have two or more chronic conditions, have at least one condition being unstable, and have at least two risk factors from at least two separate domains. For more information, take a look at our Complex CCM page.
Can we bill code 99490 for 20+ minutes of care plan creation or a month where 20+ minutes of care coordination were done?
Yes. Not all months will include a phone call to the patient. These other billable events will be sent to you as well and are permitted under CMS rules.