1. Meet practice eligibility requirements.
Determine whether or not your practice is eligible to report CPT 99490 under the PFS. Confirm that your practice is NOT participating in a Medicare model or demonstration such as PCP or MAPCP. You may report CCM only for those Medicare patients in your practice not attributable to these models. See the Dulcian white paper, “Implementing Chronic Care Management (CCM) – CPT 99490” , for more information.
2. Be sure that you have implemented a certified EHR.
Ensure that your practice uses a certified EHR. Under the Rule, this may be certified as a 2011 or 2014 EHR. Many CCM Scope of Service Elements must be stored in your certified EHR.
3. Choose eligible patients.
If your practice is eligible, examine your Medicare patient population for those patients who meet the CCM eligibility requirements. CMS intention is clear in the “discussion” of the Final Rule that you must select candidates from your most severely ill patient population to receive CCM services from your practice. Patients must have at least two or more chronic conditions that are expected to last at least 12 months or until death and conditions which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. In most cases, patients may have more than two chronic conditions that place them at risk of death. These patients will benefit the most from CCM services.
4. List your beneficiary patients.
Create a list of patients that have been selected as likely qualified CCM patients and identify the most appropriate clinician within your practice to furnish CCM services.
5. Initiate CCM with a face-to face visit.
The identified clinician must perform an initiating CCM face-to-face visit with each selected patient, during which the details of CCM are discussed. The clinician must ensure that the patient understands the full scope of CCM including the fact that their informed consent is required. This visit is required but not billed under CCM CPT 99490 using E/M codes. This may be an AWV, IPPE, or comprehensive E/M exam, but CCM must be discussed during the visit. If it is not, the visit does not count and a CCM initiating visit must take place.
6. Obtain patient consent.
Obtain written informed patient consent and counsel the patient about CCM including the scope of service, the fact that only one practitioner can be authorized during any month, the patient’s right to revoke services, and methods for sharing the agreement with the patient. Patient consent must be documented in the EHR. In addition, it is also necessary to document the patient’s revocation of consent or death.
7. Create the Care Plan.
Create a comprehensive patient-centered care plan for each of your patients who have consented and share it with the relevant patient. This plan must reflect the patient’s values and needs. Your EHR must capture all of the plan information. Your practice care team must have 24/7 electronic access to each patients’ plan. Outside providers must also have electronic access (no fax communication is allowed) but this does not necessarily have to be provided through your EHR. As CCM services are furnished, make sure that the plan is monitored and revised as needed.
8. Perform necessary Scope of Service.
Deliver the additional elements of Scope of Service of CCM:
Store structured data about the patient in your certified EHR including a full list of problems and medications, care coordination and ongoing clinical care.
Deliver Continuity of Care – Your practice must ensure that the patient will have access to routine successive appointments with the same designated clinician or care team.
Provide 24/7 access to care.
The patient must be able to reach his/her designated clinician or care team. Advisably, this means returning calls within 24 hours. The care team must meet the EHR requirement for the CCM Scope of Service as outlined in the CMS May 2015 literature.
Manage care transitions between and among other providers and after hospital and/or other facility discharges.
Include coordination with home and community-based providers.
Electronic clinical summaries must be available.
Deliver Chronic Care Management (CCM) services.
9. Log time spent delivering CCM services.
Document the time spent delivering CCM. You must log at least 20 minutes of qualified services on behalf of each patient who receives CCM services during a calendar month. CMS has not specified the data elements for such a log. Be sure that the information contained in the log is sufficient to determine that all requirements for delivering CCM services are met and documented.
10. Determine whether outsourcing is right for your practice.
Consider outsourcing CCM services and documentation. CMS permits outsourcing of CCM services within the US. CMS does not specify the format or content for this log or the required documentation. You can free your staff from some of these tasks and allow them to focus on patient-facing care. Outsourcing services and proper documentation allow your practice and patients to benefit from the ability to provide and track services. See “Can CCM Services be Sub-Contracted to Case Management Companies.”
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