Awareness : Did You Know? 2017

Did You Know? Weekly Educational Series #20

For the Week of July 17, 2017-Chronic Care Management (CCM))

The following questions originated in the Ask-the-contractor (ACT): Chronic Care Management Services (B) event. The questions are followed by the appropriate answer and the sources of the information are provided.

Q1: What is the definition of ‘clinical staff’?
A1: ‘Clinical staff’ are either employees or those working under contract for the billing practitioner to whom Medicare directly pays for chronic care management (CCM). CCM services that are not provided personally by the billing practitioner should be provided by clinical staff under the direction of the billing practitioner on an “incident to” basis, subject to applicable State law, licensure, and scope of practice.
In addition, time spent by clinical staff may only be counted if Medicare’s “incident to” rules are met such as supervision, applicable State law, licensure, and scope of practice. Of course, other staff may help facilitate CCM services, but only time spent by clinical staff can be counted. Additionally, practitioners should consult the Current Procedural Terminology® (CPT®) manual definition of the term ‘clinical staff.’


Q2: If the billing practitioner furnishes CCM services directly, does their time count toward the clinical staff time required to bill CCM?
A2: If the billing practitioner provides the clinical staff services themselves, the time of the billing practitioner may be counted as clinical staff time.

Q3: Is a new patient consent form required each calendar month or annually?
A3: Patient consent should be documented at the start of CCM services or at least annually. A new patient consent is only required if the patient changes billing practitioners, in which case a new consent must be obtained and documented by the new billing practitioner prior to furnishing the service.

Q4: Can the patient consent be applied to other providers within a practice?
A4: The patient consent can be applied to any provider within the same billing group. If a valid consent is on file, then it would not need to be obtained per each provider. However, if a patient should transfer their CCM services to a practitioner who bills independently of the group, then a new consent form should be obtained and documented.

Q5: If a medical assistant is State certified, can their time be counted toward the clinical staff time?
A5: Yes, subject to the applicable State law, licensure, and scope of practice. Credentials of clinical staff must be notated in the medical record for all CCM entries.

Q6: What constitutes a billing practice (billing group)?
A6: The billing practice is considered the same billing group under the same national provider identifier (NPI).

Q7: Are specific times allotted for each service provided, such as medication refill, reviewing consult notes, scheduling appointments with specialists, etc.?
A7: There are no specific allotted times. The time would depend upon what activity is taking place. The important thing to remember is to document the staff member’s credentials and the time it took to provide each service.

Q8: What date of service should be used on the claim and when should the claim be submitted?
A8: The CCM service period is one calendar month. The Centers for Medicare & Medicaid Services (CMS) expects the billing practitioner to continue furnishing services during a given month, as medically necessary, after the minimum clinical staff time threshold to bill is met. Practitioners may report CCM at the conclusion of the service period, or after completion of the minimum clinical staff service time. This time may accumulate throughout the month, and once the 20-minute requirement has been fulfilled, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month.

Q9: Can we bill CPT® 99489 more than once? For instance, if we exceed 120 minutes of complex CCM, can we bill more than one CPT® 99489?
A9: We have reached out to CMS for their response and will update this document once it is received.
Keep in mind, in order to bill for complex CCM (CPT® 99487 or 99489), the comprehensive care plan must be established or substantially revised, and the billing practitioner must personally perform moderate to high complexity medical decision-making during the service period (calendar month), as the CPT® code descriptors include these services.

Q10: If a provider leaves the practice, can we continue CCM for a patient with a new provider within the same billing group?
A10: Since the same group is billing for the CCM services, the patient’s CCM can be transferred to another provider in the billing group. However, if the patient has not had a visit within the past year, the patient may need to have a new initiating visit with the new provider.

Q11: What is meant by ‘no other diagnostic limitations’?
A11: This means there is no specific diagnosis required. However, there is a requirement that the patient have two or more chronic conditions, as defined by CMS.

Q12: We are an HIV medical practice and have a pharmacist on staff. Would the pharmacist be eligible to provide CCM?
A12: Pharmacists can be considered clinical staff, provided their credentials meet the requirements outlined in A1 above.

Q13: Can medical assistants have national accreditation to qualify as clinical staff?
A13: Medical assistants, as well as other practitioners, can be certified nationally or at the State level and qualify as clinical staff, provided their credentials meet the requirements outlined in A1 above.

Q14: Is there a list for complex and non-complex diagnoses?
A14: Chronic conditions recognized by Medicare, whether complex or non-complex, are included within, but are not limited to, the diagnoses found in Chronic Conditions Data Warehouse .

Q15: Can CCM be billed within the same month as G0506?
A15: Yes. However, G0506 is an add-on code to the initiating visit, not the CCM.

Q16: Does the patient have to sign off on the care plan?
A16: Documentation of the care plan being provided to the patient must be notated in the medical record. However, it is not a requirement that the patient actually sign off on the care plan.

Q17: If a patient has web-enabled access to their account in the electronic medical record (EMR), is this considered appropriate access to the chronic care?
A17: As long as the patient has 24 hours-a-day/7 days-a-week access to their CCM for urgent needs, then yes, it would qualify.

Q18: Can an Annual Wellness Visit (AWV), CCM, and a G0506 be billed for the same visit?
A18: Although the AWV and G0506 can be billed during the same visit, the CCM services are not typically provided on the same billing date.

Q19: If a patient is enrolled in the CCM program through our practice and has not been seen in 12 months, should CCM services be held until the patient has a follow-up appointment?
Q19: If the patient has not been seen in over one year, a new initial visit should be conducted before billing for additional CCM services.

Q20: If a patient is in the hospital for a day or two and is in CCM and we do not bill for transitional care management (TCM), can we still bill for CCM as long as we meet the 20-minute threshold?
A20: The CCM service code(s) could be billed during the same calendar month as TCM, if the TCM service period ends before the end of a given calendar month and a qualifying amount of time is spent furnishing CCM services subsequently during that month.
For complex CCM, there must be moderate or high complexity level of medical decision-making by the billing practitioner during the remainder of the month.

Q21: Are sample care plans available to review to help our practice build our care plans?
A21: There are no sample care plans. However, the elements of documentation within the care plan are detailed in the CCM Services Fact sheet .