Helping Physicians Succeed with Chronic Care Management

“Chronic care management services of at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.” (CMS Final Rule, October 31, 2014)

CMS has not defined a specific list of conditions. Some examples of chronic conditions include the following (and there may be many more that qualify):

• Alzheimer’s disease and related dementia
• Arthritis (osteoarthritis and rheumatoid)
• Asthma
• Atrial fibrillation
• Autism spectrum disorders
• Cancer
• Chronic Obstructive
• Pulmonary Disease
• Depression
• Diabetes
• Heart failure
• Hypertension
• Ischemic heart disease

Physicians and the following non-physician practitioners may bill the new CCM service:

• Certified Nurse Midwives;
• Clinical Nurse Specialists;
• Nurse Practitioners; and
• Physician Assistants.

Note: Only one practitioner may be paid for the CCM service for a given calendar month.

Yes. CMS requires the billing practitioner to furnish an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), or comprehensive evaluation and management visit to the patient prior to billing the CCM service, and to initiate the CCM service as part of this exam/visit. Managing Care Solutions can assist your practice in the hiring, training, and QA of medical office assistants to perform these AWVs.

• Establishment of an individual’s medical/family history.
• Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.
• Measurement of an individual’s height, weight, BMI (or waist circumference, if appropriate), BP, and other routine measurements as deemed appropriate, based on the beneficiary’s medical/family history.
• Detection of any cognitive impairment that the individual may have as defined in this section.
  Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations.
• Review of the individual’s functional ability and level of safety based on direct observation, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available screening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations.
• Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on
• Immunization Practices (ACIP), as well as the individual’s health status, screening history, and age-appropriate preventive services covered by Medicare.
• Establishment of a list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an IPPE, and a list of treatment options and their associated risks and benefits.
• Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self-management, or community-based lifestyle interventions to reduce health risks and promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition.
• Any other element(s) determined appropriate by the Secretary of Health and Human Services through the National Coverage Determination (NCD) process.

Managing Care Solutions can assist your practice in the hiring, training, and QA of medical office assistants to perform these AWVs.

A practitioner must inform eligible patients of the availability of and obtain consent for the CCM service before furnishing or billing the service. Some of the patient agreement provisions require the use of certified Electronic Health Record (EHR) technology.

Managing Care Solutions can provide your practice with informative patient brochures, required consent forms, and templates for the patient’s care plan.

Patient consent requirements include:

• Inform the patient of the availability of the CCM service and obtain written agreement to have the services provided, including authorization for the electronic communication of medical information with other treating practitioners and providers.
• Explain and offer the CCM service to the patient. In the patient’s medical record, document this discussion and note the patient’s decision to accept or decline the service.
• Explain how to revoke the service.
• Inform the patient that only one practitioner can furnish and be paid for the service during a calendar month.

This agreement process should include a discussion with the patient, and caregiver when applicable, about:

• What the CCM service is;
• How to access the elements of the service;
• How the patient’s information will be shared among practitioners and providers;
• How cost-sharing (co-insurance and deductibles) applies to these services; and
• How to revoke the service.

Informed patient consent need only be obtained once prior to furnishing the CCM service, or if the patient chooses to change the practitioner who will furnish and bill the service.

(1) Electronic Health Record (certified as a 2011 or 2014 certified EHR/EMR) with capacity to form a structured clinical summary:

• Demographics
• Full List of Problems
• Medications and Medication Allergies

(2) Patients must have 24/7 timely access to address urgent chronic care needs.

(3) Provider must offer continuity of care with provider or member of the care team, so that patient is able to get successive routine appointments.

(4) Care Management Services including:

• Systematic assessment of the patient’s medical, functional, psychosocial needs
• System based approaches to ensure timely receipt of all recommended preventative services
• Medication reconciliation with review of adherence and potential interactions
• Oversight of patient self-management of medications

(5) Development of an electronic patient-centered care plan.

• Must be able to share electronically with other providers
• Provide a copy to patient

(6) Management of care transitions

• Referrals to other clinicians
• Follow-up after an emergency department visit
• Follow-up after discharge from hospital, SNF, or other health care facility
• Must be able to electronically share patient care plan, clinical summary, and other relevant documents

(7) Coordination with home and community-based service providers.

(8) Provider must offer enhanced opportunities for patient to communicate with provider through the use of secure messaging, internet, or other asynchronous non face-to-face communication methods.

(9) Patient’s must sign a consent that includes:

• Nature of CCM and how it may be accessed
• They can stop services at any time
• Only one provider can provide CCM at one time
• Patient’s information will be shared with other providers across the care continuum
• The patient will be responsible for the co-insurance payment

Managing Care Solutions will:

• Assist practices with work flow development; provide brochure and consent forms, as well as templates for the patient’s care plan.
• Provide monthly non-face-to-face care management services telephonically by a CCM Coordinator. CCM Coordinators are certified Medical Office Assistants. They are given specialized training and are supervised by MCS’ Registered Nurses.
• The CCM Coordinator will function as part of the practice team, working closely with each medical practice to deliver the CCM scope of service requirements for billing.
• The CCM Coordinator will document his or her work in Smartlink Health’s Chronic Care Management solution.
• MCS will have read-only access to practice EHR;
• Managing Care Solutions can also assist your practice in the hiring, training, and QA of medical office assistants to perform Annual Wellness Visits.

Smartlink Health is our technology partner. Smartlink is a cloud-based platform that provides technology for:

• Electronically transmitting referrals, care plans, and other documents
• Documenting CCM activities. A built-in timer records the minutes for care coordination activities
• Auditable CCM time tracking records for practice
• Real time management of minutes and follow-up tasks needed per patient
• Asynchronous patient communication via text messaging (can use for transmission of care plans)

Learn more at www.smartlinkhealth.com.

Call us – (980) 264-7006. We’re happy to help!