Electronic Health Reporter

Guest post by Dr. Seth Flam, board certified in Family Practice and co-founder and CEO of HealthFusion.

CMS has some good re-imbursement news for primary care physicians for 2015: It has announced a new chronic care management program starting January 1 that will allow providers to bill for providing care management for patients with chronic conditions.

In other words, primary care providers can get paid for care they likely already provide.

With this new program, chronic care management can provide a good source of revenue for a practice, if designed, managed and billed correctly. Since a provider can bill $42.60 per patient per month, with a reasonable number of patients with chronic conditions in the practice, a provider can easily see revenue of more than $50,000 per year.

Annually: $511.20 per year per patient X 100 patients = $51,120 per year

(Assumes the provider bills for each patient 12 months out of the year)

But—there are very specific things providers need to know about the program, and particular requirements they need to follow in order to get paid. Here is a preview of some of the requirements:

1. Identify chronic care patients who qualify.
2. Eligible patients include those with two or more chronic conditions expected to last at least 12 months, or until death, that place the individual at significant risk of death, acute exacerbation/decompensation, or functional decline.
3. Only one provider can bill for the chronic care management code for a patient in a 30-day period.
4. The billing provider must have a signed agreement with the patient allowing them to bill for these services and detailing cancellation rights, co-payments and types of services.
5. Among other things, the provider needs to supply 20 minutes or more of chronic care management services per patient per 30 day billing period.
6. The provider will need to create a patient-centered care plan document compatible with the patient’s choices and values.
7. The provider must provide either a written or electronic copy of the care plan to the patient.
8. The provider will need to manage care transitions between and among health care providers and settings.
9. Bill in accordance with CMS requirements using CPT code 99490, making sure the practice’s EHR software provides the information needed to manage and bill for this program.
10. Begin the process of establishing practice processes and gathering patient agreements soon, although the program doesn’t go into effect until 2015.

CMS just announced the finalized revisions to the 2014 PFS final rule regarding “incident to” services. As finalized, CCM services provided by clinical staff incident to the service of a practitioner can be furnished under general supervision of a physician or other practitioner and the clinical staff does not need to be a direct employee of the practitioner or practitioner’s practice.

What the Practice’s EHR Software Should Do

Many stakeholders have expressed a belief that the CCM program is premature, given the requirements for interoperability between EHRs. However, if the practice has an EHR designed to meet the requirements, it should be able to manage and bill for the new code. Among the requirements to look for:

1. To effectively manage this program, the practice needs an EHR with an interface that creates a virtual list of all patients that have FFS Medicare and at least two chronic conditions.

2. Next the EHR must narrow that list of patients “real-time” to those who:

• Have had activity outside of an in-person or telemedicine encounter
• Have a signed CCM patient agreement incorporated into the medical record

3. Finally, the EHR must have a way to create bills with the CPT code automatically for each 30-day period for every eligible patient. It must track whether the code was already billed during the 30-day period and also remind the biller to bill the service for eligible patients before the billing period expires.

CMS has shown some flexibility in its EHR requirements for this program. Originally, the agency proposed that a 2014-certified system would be required, but it recently announced that providers can bill with the certified EHR in use on December 31 of the prior year for the EHR Incentives Programs.

I believe this program is a step in the right direction. Chronic diseases are among the most prevalent, costly and preventable of all health problems, as the CDC has pointed out. Multiple studies have shown that care management of this type reduces total costs of care for patients with chronic conditions while improving outcomes. And certainly, the population of patients with chronic conditions only continues to increase. But historically, providers were not reimbursed for care management that was not face-to-face.

Providers should get started now on preparing for the chronic care management coding program; learn the requirements; and begin understanding how their software can track which patients are eligible for billing and start to incorporate the CCM patient agreement into their patient intake paperwork. By working with their EHR vendors today, they can increase the chance they will get paid next year for this important care.