Chronic Care Management and Medicare AdvantageCMS clarified lingering questions about the new Chronic Care Management code under Medicare Advantage plans recently in a memo to Medicare Advantage organizations and on other topics in a February Q&A session at the end of an MLN Connects National Provider Call.

In the memo regarding Medicare Advantage, Kathryn Coleman, director of the Medicare Drug & Health Plan Contract Administration Group, confirmed that the CCM was a covered Medicare Part B service “included in the basic benefit offered by every MA (Medicare Advantage) plan.”

However, Coleman noted that Medicare Advantage organizations “have wide latitude” when it comes to furnishing care coordination services to beneficiaries.

“Medicare Advantage regulations … expressly preclude CMS from interfering in payment rates agreed to by an MA plan and its contracted providers,” Coleman said. Whether such a plan pays physicians for furnishing care coordination via the Chronic Care Management code or some other mechanism “can vary depending on the contract agreement in place,” she added.

The clarification from CMS was apparently in response to a request from medical societies, and was issued on April 10, the same day that a conference call with these groups was held.

Coleman included additional information in the memo regarding patients enrolled in preferred provider organizations who “have the option to obtain covered services from non-contracted providers.”

She explained that if a patient chooses an out-of-network provider to provide care coordination management services — and the criteria for billing the CCM code is satisfied — the Medicare Advantage plan must pay for the services as an out-of-network physician service.

Patients would be responsible for the out-of-network cost-sharing in this scenario, she added.

CMS Provided Additional Answers in MLN Connects Call

In a CMS MLN Connects National Provider Call on February 18, 2015, CMS staff answered multiple other questions on the Chronic Care Management program. These included:

Q: Can the charting time by the nurse be counted as time toward the CCM?

A: We think it certainly can. RN is certainly clinical staff, and if they are doing chart documentation related to chronic care management services, that time should certainly be counted.

Q: If you see the patient for a comprehensive visit and obtain informed consent at that time, and then don’t see the patient, provide this service, or don’t have enough minutes or for whatever reason, don’t bill the service in the next month, is that still sufficient to, a month or two down the road, start billing the service?

A: You can certainly bill the service in another month. You couldn’t bill it for that first month where you didn’t meet the 20-minute timeframe.

Q: On the place of service code that we should be using when billing the service: If we’re filing our claims using the office service code of 11, are we doing that correctly since it’s not specified?

A: Yes, since at this point we have not specified, that would certainly be fine.

Q: Can a 99091, which is collection and interpretation of physiological data of at least 30 minutes, be billed in addition to the CCM 99490?

A: This question is one that we received a lot after the rule went out. No, it cannot be billed during the same service period. If you look in the CPT guidance, it’s a code that’s excluded from billing during the same month.

We’ll provide more Q&A from CMS on Chronic Care Management coding in our next blog.

Resources

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 http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-02-18-CCM-Transcript.pdf

See CMS’ Chronic Care Management Fact Sheet at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf