Chronic Care Management (CCM) is a new Medicare service for 2015. It is intended to pay separately for non-face-to-face care coordination services furnished to Medicare beneficiaries with two or more chronic conditions. The codes were described in last year’s final rule but the actual HCPCs code has not been announced.
GXXX1 – Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 20 minutes or more; per 30 days.
As stated, in order to bill for this code, at least 20 minutes of CCM services must be furnished during the 30-day billing interval. Clinical staff time can be counted toward the minimum amount of service time for services furnished incident to the billing practitioner’s services. An exception is being made so these services can be performed under general supervision when services are performed outside of the practice’s normal business hours by clinical staff who are direct employees of the practitioner or practice. One of the required elements of the CCM service is the availability to a beneficiary 24-hours-a-day, 7-days-a-week.
The CCM services include:
- Access to care management services 24-hours-a-day, 7-days-a-week, which means providing beneficiaries with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.
- Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
- Care management for chronic conditions including systematic assessment of patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.
- Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.
- Management of care transitions between and 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 discharges from hospitals, skilled nursing facilities, or other health care facilities.
- Coordination with home and community based clinical service providers as appropriate to support a beneficiary’s psychosocial needs and functional deficits.
- Enhanced opportunities for a beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary’s care through, not only telephone access, but also through the use of secure messaging, internet or other asynchronous non face to-face consultation methods.
To bill for these services, practitioners must:
- Inform the beneficiary about the availability of the CCM services from the practitioner and obtain his or her written agreement to have the services provided, including the beneficiary’s authorization for the electronic communication of the patient’s medical information with other treating providers as part of care coordination.
- Document in the patient’s medical record that all of the CCM services were explained and offered to the patient, and note the beneficiary’s decision to accept or decline these services.
- Provide the beneficiary a written or electronic copy of the care plan and document in the electronic medical record that the care plan was provided to the beneficiary.
- Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of a 30-day period) and the effect of a revocation of the agreement on CCM services.
- Inform the beneficiary that only one practitioner can furnish and be paid for these services during the 30-day period.