Medicare’s New Chronic Care Management Codes for MDs: Clinical IT and Other Requirements

Jan. 14, 2015
While physicians can now bill Medicare for chronic care management of their patients, one physician expert cautions that, along with real potential for significant income growth, there are rigorous process and IT requirements involved

As of January 1, the Medicare program began paying physicians for chronic care management, authorizing a monthly payment per Medicare enrollee (estimated to average out nationally at approximately $42.60) to every Medicare-participating physician who fulfills a set of requirements for the care of patients with multiple chronic illnesses.

Any physician seeking to participate (and certain physician assistants and nurse practitioners are also eligible to participate) needs to be the primary care physician for a patient with two or more chronic conditions, and needs to meet numerous requirements around using an electronic health record (EHR) for documentation, sharing continuity of care documents (CCDs) with physician and other clinician colleagues, and provide care coordination services to her or his patient every month. The American College of Physicians (ACP), the national professional association for internal medicine specialists, has provided a succinct and helpful summary on the subject.

One physician executive who is knowledgeable about the topic is Ron Ritchey, M.D. Dr. Ritchey is the chief medical officer at eQHealth Solutions, The Medicare QIO for Louisiana (every state has a quality improvement organization interfacing between the Medicare program and providers, and eQHealth Solutions is the designated QIO in Louisiana).

A not-for-profit non-governmental organization, eQHealth Solutions functions both in its core QIO capacity, and also has commercialized several IT solutions for providers in areas around population health and care management. Dr. Ritchey spoke recently with HCI Editor-in-Chief Mark Hagland regarding the new reimbursement opportunity around care management. Below are excerpts from that interview.

What is the policy context of the new Medicare physician reimbursement opportunity?

Yes, Medicare has for some time come to the conclusion that they have a lot of members who have multiple diseases, and that much of their cost is coming out of that. And through a number of demonstrations, they’re coming to the conclusion that primary care physicians’ relationships with those patients is a critical issue in reducing care costs. This coordinates with the concepts of patient-centered medical homes, electronic health records, and interoperability. Historically, Medicare has been a payer of evaluation and management codes. In other words, a patient sees a physician, there’s a laying on of hands, diagnosis and treatment take place, and then a bill drops. Now recently, at Medicare, they’ve been moving towards the recognition that some necessary services haven’t taken place because there’s no mechanism for them. And these services are very important—a lot of coordinated services were not being reimbursed, and therefore, very little effort was put into them; the physicians were focused on the management and evaluation component.

Ron Ritchey, M.D.

So Medicare decided to pay for a transitions care code, it’s a CPT code. That was touching their toes into the water. Now, beginning January 1, they’ve come out with this chronic condition management, or CCM, code, 9940 is the CPT. So basically, the physician has the responsibility to identify a qualified Medicare beneficiary—someone with at least two identified chronic conditions. Someone has to explain the process, the patient has to provide consent and you have to maintain that information on consent in your electronic record. And then you have to meet a number of conditions to qualify. It averages about $40 across the country; and it’s one payment per month. And it can only be billed by one physician per month.

How many physicians are actively documenting their chronic care management now, a couple of weeks into the new year?

Right now, it’s very few. Most don’t understand it, and many who are aware of it don’t have enough depth of understanding to feel comfortable doing it, and of those who do understand it, only a few of them have developed the mechanism or infrastructure needed. So not many have done it yet.

What process and IT requirements do physicians need to fulfill in order to participate?

First, let me give you a broad overview. This is an opportunity to bring in a significant amount of new money into practice without having to expend an unreasonable amount of effort. I think many physicians in a solo shop or small practice may find the regulations a bit burdensome. They might want to partner with a vendor to have the vendor to provide some backup services.

There are about 50 pages on this in the federal register. And even with those 50 pages, there’s still a certain amount of ambiguity that remains to be ironed out. So there are three steps: first, identify the qualified beneficiaries and get their consent. Second, meet the technology requirements, which are part of a major initiative of Medicare’s around chronic record management. Third, the practitioner has to execute the chronic care services to document it to Medicare.

In the first stage, identifying the qualified beneficiaries, they have to have at least two chronic conditions that are continuous. Medicare has not specified which ones, but they have be conditions that last 12 months; they have to place the patient at risk for death or acute exacerbation or decompensation of their condition, such as CHF or COPD. Let’s say you have emphysema, and on a daily basis, you get by OK. Your oxygen levels may be low or so on; but if you catch a winter cold or cough, your condition becomes much more compromising, so you decompensate, and may wind up in a hospital. The last one is functional decline. So let’s say a person has rheumatoid arthritis, and they’re on medications, and are doing relatively well, are mobile, are getting around, but they quit taking their medicine; their joints flare up and swell, and the patient can’t get out of bed or take care of themselves, that would be an example of functional decline.

And there are technological requirements beyond a core EHR implementation, correct?

Yes. Basically, the technology requirements revolve around two components. One is having a certified EHR, but you’re not required to have met meaningful use. Second, you need an electronic plan of care created specifically for a patient and that is available to the patient either electronically or on paper, 24/7. The plan of care would identify the chronic diseases and the medications prescribed. And specifically, the EHR must include pretty standard components like demographics, problem list, medication list and allergies. Pretty much any EHR would include that. It also has to allow for the creation of a structured record, which is a standard thing also.

Next, the provider has to have the ability to create a CCD and share that CCD with other clinicians. The EHR has to house the consent form; and has to house a receipt from the beneficiary of their care plan, in other words, documenting that the beneficiary is aware of and has participated in creating their plan of care. That’s a patient-centered element. And lastly, there has to be documentation to and from home-based providers, such as home health, about the needs of the patient. And there’s actually more to the technology requirements. Specifically around the plan of care, there are some additional requirements. The plan of care has to include the following elements. It has to be based around the physical assessment, mental assessment (cognitive ability), psychosocial assessment, and cognitive, functional, and environment assessments. So, six elements are involved. You need to develop a very complete picture of the holistic status of the patient and that is not typical of most plans of care.

And there has to be an ability to share that plan of care with other practitioners and with care coordinators. For some practices, that’s problematic and would require some sort of expansion of the way they’re doing business today. There also must be an opportunity for the caregiver and beneficiary to communicate not only telephonically but also through secure messaging.

And what care coordination process requirements are involved?

The care coordination services involved have to take up at least 20 minutes, in aggregate, per month. It can be five minutes here, 15 minutes there. Now, we’re not talking about physician time here; we’re talking about behind-the-scenes care coordination time provided by the practice.

So  that means nurse practitioners, case managers, and patient educators, then?

Yes, and it could also be schedulers, coordinators—all the people trying to connect the patient with other services. But you’ve got to be able to document that; otherwise, you’re billing what would be considered a false claim. So it’s important that you emphasize to your readers that they need to be very diligent about their documentation, because when it comes to billing practices, Medicare has no sense of humor.

The other component that’s important is a continuity component. In other words, if you’re billing for chronic care management services, you have to have some kind of ongoing relationship with the patient such that the patient has the ability to schedule routine appointments with you—that’s continuity of care. There also must be an assurance that the patient can receive their preventive services; for PCPs that falls in line with standard wellness services. There also has to be documented medication reconciliation. And also there needs to be oversight of beneficiary self-management around medication.

And the last two components: there needs to be follow-up of emergency department visits; and follow-up around a skilled nursing facility or hospital admission.

I mentioned earlier there was this transitions code; you can’t bill that code in the same month as you bill the chronic care management code. The transition code is $150, for one month. And the chronic care code is $40, and it’s for every month. So billing both would be a kind of double-dipping.

How much could this care coordination potentially generate in revenue for physicians?

It’s well-established that two-thirds of Medicare beneficiaries have at least two chronic conditions, and that’s fairly universal across the country. So depending on how many patients a practice might have, it’s substantial. The average practice has about 20-22 percent Medicare patients, among primary care physicians nationwide. Recently, I talked to a group of internal medicine docs owned by a hospital. And they said, you know, Medicare is at least 50 percent of our patients. That may be slightly skewed. But if 62 percent of those patients have two conditions, then that’s almost $500 per patient, and that could mean a quarter million dollars a year per physician, in theory. And qualified practitioners include nurse practitioners and physician assistants. And one practitioner per month can bill this regarding one unique patient.

So if I’ve got 1,000 Medicare patients and my nurse practitioner has another 500 Medicare patients, we would each be billing per unique patients attached to each unique provider.

Now, Medicare has made the decision that this fee is subject to a co-pay. A standard Medicare co-pay is 20 percent. So if a fee is $42, 20 percent of that would be co-pay. So the patient would be paying about $9. Now, what if the patient has a Medicare supplement policy? That should pick up the co-pay, depending on the co-pay.

So all of this could come to nearly $500 per patient per year; and if you’ve got 1,000 Medicare patients, that means $500,000. Now that’s a top-line number; but you have to subtract the services you have to provide. So I’m recommending to physicians that they use this as a means of building the infrastructure that they need in order to develop, for example, a medical home, as well as the structures they could use in their commercial insurance-based contracts. In other words, Medicare can foot the bill for helping them to build necessary infrastructure. I wouldn’t hold this out to them as some kind of windfall involving money they can pocket. I wouldn’t recommend them to view this that way. Second, they’ve got to develop the documentation, in order to avoid charges of false claims.

What should our audience of healthcare IT leaders be thinking and doing?

Well, I think that they have to keep in mind that Medicare is likely going to be programming its computers for certain built-in exclusions—for example, the one-practitioner-per-month rule. Also, there’s a responsibility, globally, not just the IT folks, but whoever’s responsible of the practice, that if you’re going to bill for it, you need to be able to manage it. So you need proper documentation modules. So for many records, that will require some augmentation of your documentation systems. In a bigger practice, you can go ahead and make sure to obtain those modifications. If you don’t have those capabilities, you might want to approach a vendor that can help you. I basically think there will be some companies that will be help practitioners to do that.

What percentage of physicians in private practice will be doing this in a year, do you think?

Well, quite honestly, if you can explain the pitfalls, it really should be taken up pretty rapidly, because there’s a lot of money on the table here. And frankly, most practices not only need the cashflow; they need to develop the infrastructure necessary to provide this kind of care management. There is a fair amount of detail in the regulation. A doctor could start billing tomorrow for a new code; but he’ll need to document all this.

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