New Medicare Payment Policy Opens the Door for Case Managers

Monday, December 1, 2014
Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

On October 31, 2014, the Centers for Medicare and Medicaid Services (CMS) released the 2015 Medicare Physician Fee Schedule (MPFS) Final Rule, which establishes payment levels and policy changes for Medicare Part B services. In the Final Rule, CMS states that beginning on January 1, 2015, it will pay for non-face-to-face chronic care management services, including the ongoing development and revisions of care plans, communication with other treating providers, and medication management.

Under this program, Medicare will pay physicians, advanced practice nurses, physician assistants, clinical nurse specialists, and certified nurse midwives a monthly fee for chronic care management (CCM) provided to Medicare beneficiaries. Commencing in 2015, certain care coordination, wellness, and behavioral health telehealth services will also be covered. Previously, CMS primarily paid physicians and other health care practitioners for care management services as part of face-to-face visits. The 2015 MPFS expands Medicare payment policy to include non-face-to-face management services that previously have not been reimbursed.

Primary Care and Chronic Care Management
CMS continues to emphasize primary care by paying for chronic care management (CCM) services – non-face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more). Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.

In the Final Rule, CMS outlines the following points related to chronic care management:

  • CMS defines CPT Code 99490 as: Chronic care management services, 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 will allow $42.60 for CPT code 99490, which denotes non-face-to-face CCM. To bill this code, physicians or their clinical staff members must spend at least 20 minutes performing the CCM services. Direct supervision is not required, which means that nursing staff or non-physician practitioners can render CCM even if the physician is not in the office.
  • Physicians may bill this code no more frequently than once per month per qualified patient.
  • For CCM payment in 2015, physicians must use EHR technology that meets either the 2011 or 2014 certification criteria.

The American Academy of Family Physicians (AAFP) has developed a summary of the 2015 Medicare Physician Fee Schedule. According to the AAFP, CCM services must include:

  • Access to care management services 24-hours-a-day, 7-days-a-week, which means providing beneficiaries with a way to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs at all times.
  • Continuity of care with a designated practitioner or member of the care team with whom the patient is able to have successive routine appointments.
  • Care management for chronic conditions, including a systematic assessment of the patient’s medical, functional and psychosocial needs; system-based approaches to ensure a timely receipt of all recommended preventive care services; medication reconciliation with a review of adherence and potential interactions; and oversight of patient self-management of medications.
  • Documentation of a patient-centered care plan to assure that care is provided in a way that is congruent with the patient’s choices and values. A plan of care is based on physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan for all health issues.
  • Management of care transitions among health care providers and settings, including referrals to other clinicians, follow-up after a beneficiary visit to an emergency department and follow-up after discharge from a hospital, skilled nursing facility or other health care facility.

As a result, CMS is now making it easier for physicians to delegate care management to practice staff. The final rule also allows providers to oversee the time spent by clinical staff members, which can count toward the required 20 minutes of work.

In addition, the AAFP overview summarized how CCM service providers must have functioning electronic care planning capabilities and utilize electronic health records (EHRs). Specifically, the information exchange platform must include an electronic care plan that is accessible to all providers within a practice and able to be shared electronically with care team members during and outside of the practice’s normal business hours.

Telehealth Benefits
In addition to CCM services, expanded telehealth coverage will increase access to specialty services for rural patients and their caregivers by allowing them to stay in their own community rather than travel long distances to a provider’s office. It will also decrease the number of cancelled appointments due to weather/travel conditions; reduce the time for investigation, diagnosis, and treatment through quicker consultations; and increase health education opportunities for patients and their families.

The American Telemedicine Association (ATA) notes that the following services can be furnished to Medicare beneficiaries under the new telehealth benefit:

  • Psychotherapy services: CPT codes 90845 (Psychoanalysis); 90846 (family psychotherapy without the patient present); and 90847 (family psychotherapy - conjoint psychotherapy with patient present).
  • Prolonged services in the office: CPT codes 99354 (prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour should be listed separately in addition to code for office or other outpatient evaluation and management service); and 99355 (prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes should be listed separately in addition to code for prolonged service)
  • Annual wellness visit: HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan of service, initial visit); and G0439 (annual wellness visit, includes a personalized prevention plan of service, subsequent visit).

Additionally, the ATA further praised the ruling by saying:

"While CMS has once again not allowed payment for data collection, the battle has taken a small but significant turn. First, CMS has agreed that data collection is a valuable service and should be incorporated into chronic care management. Second, there are two valuable service codes on the books: 99090 (Analysis of clinical data stored in computers, e.g., ECGs, blood pressures, hematologic data); and 99091 (Collection and interpretation of physiologic data, e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation, when applicable, requiring a minimum of 30 minutes of time."

Final Thoughts
It is encouraging to see CMS acknowledge and move forward with the need for payment of chronic care management and telehealth services. However, I echo CMSA executive director Cheri Lattimer’s thoughts from a recent edition of CMSA Today, "It is extremely important that as case managers, we begin to strategize how qualified, professional case managers can be recognized as providers of chronic care management and case management services and work toward achieving Medicare billing status." We need to continue to work towards that goal.