Chronic care managementIn our previous blog post, we discussed clarification provided by CMS on the Chronic Care Management coding program, which has generated many questions. You can read the first blog post now. Here is the second part of the summary of the Q&A session from the CMS MLN Connects call on February 18, 2015:

Q: Regarding the requirement that we share the care plan information electronically with other providers; what happens if one of the providers cannot receive that information electronically?

A: We talked to the Office of the National Coordinator for Health IT about this, but apparently some providers do have a system, Certified EHR, that translates the CCDA language into a fax for recipients who don’t have that electronic receipt capability. And you could certainly use that if your practice’s Certified EHR has that capability. ONC has mentioned that their interoperability policies in the next few years should help resolve this issue and move all providers towards being able to receive and not just send electronically. But in the meantime, I would just use a HIPAA-compliant encrypted email, or a workaround if your Certified EHR provides it, or work with another provider.

Q: Is a yearly renewal of the consent form a requirement?

A: No, we did not require it annually. In the 2014 Final Rule, we said that you don’t have to repeat the consent unless the patient changes practices and someone else is going to bill.

Q: Can we provide Chronic Care Management services for 2 or 3 years? Or is there a limit on the amount of time for which we can provide the services?

A: No, there is no cap for the beneficiaries, as far as benefits go. There is no restriction.

Q: Can we use the time that it takes to create the electronic care plan as part of the 20 minutes attributed to that month?

A: I would think so, so long as clinical staff is doing that activity.

Q: Can you clarify the statement that there is no requirement for “Certified EHR in 2015” to generate the care plan? So you could have a written care plan in 2015, but you have to electronically capture the information which goes on the plan. Am I understanding that correctly?

A: That’s correct.

Q: If after the initial face-to-face visit where the care plan is discussed, the care plan is discussed and documented in that note, does that count as the electronic care plan for Chronic Care Management?

A: Wherever is in the medical record, it just has to be electronically captured. And just be aware if it includes information around medication, just reference back to the first scope of service element for demographics, problems, medications, allergies, etc., that do have to be documented in a Certified EHR format, an acceptable one. So make sure that those pieces of it are in the certified format.

Q: But those are two separate documents, aren’t they? The clinical summary and the electronic care plan? Or they could be the same?

A: Right, but I’m assuming there are probably other places in your medical record where you referenced those things. So wherever they are referenced in the medical record, they should be referenced using “certified technology.”

Q: Does the 20-minute interaction have to be non-face-to-face? Or can it take place in a meeting at the patient’s home or if one of our health partners were to meet them offsite somewhere?

A: The service needn’t be exclusively non-face-to-face, but that they are the kind of services that are generally furnished non-face-to-face. If they happened to take place face-to-face as opposed to say, electronically, then they could be counted. But they wouldn’t ordinarily be furnished as face-to-face.

Q: Regarding the capturing of the actual 20 minutes: Can it be that we document in the electronic medical record in increments of 5, 10, 15 minutes, or does there actually need to be kind of a timekeeper that keeps it within a minute, 30 seconds, that type of thing for documentation?

A: For this service, we have not been any more prescriptive than it has to be at least 20 minutes. You may want to talk to your Medicare Administrative Contractor, your claims adjudicator, to see if they have any documentation requirements and what they typically use when they go in to audit timed services.


You can learn more about Chronic Care Management in our Resource Center, where we have an archived webinar, infographic and two white papers, including a sample Patient Agreement.

You can read the full transcript of this MLN Connects National Provider Call at

See CMS’ Chronic Care Management Fact Sheet at