You can deliver chronic care services; here’s how

Robert A. Dowling, MDIn 2015, the Centers for Medicare & Medicaid services (CMS) began separately paying for the chronic care of patients not conducted in face-to-face encounters with a fee schedule service known as “Chronic Care Management” (CCM) (bit.ly/Caremgt). Predicated on the belief that Medicare patients with multiple chronic conditions have opportunities for better care, CMS created this category of service to reimburse physicians and their staff for coordinating that care-outside of an office visit. CMS contemplated that CCM services would be billed most frequently by primary care practitioners but also wrote, “in certain circumstances, specialty practitioners may provide and bill for CCM.”

Some urology practices may be contemplating delivering CCM services to eligible patients, and this article will answer key questions about the program and features to consider when making that decision.

What type of patients are eligible for CCM, and are they found in your urology practice? CMS defines an eligible patient as having “multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.” While there is no inclusive list of chronic conditions, guidance from CMS can be found in its reference to the 19 conditions for which CMS tracks utilization and appending information (bit.ly/CMSchronicconditions).

Also by Dr. Dowling: How will urologists fare under 2018 MIPS rule?

It is likely that many patients in a urology practice have two or more of these conditions, and a simple query of a practice management or electronic health record database might be the first step to screen for these potential patients. Other chronic conditions not on this list could potentially include bladder cancer or kidney cancer. It could even be argued that urinary retention or incontinence is a chronic condition. To be eligible, though, the patient must also be at significant risk of death, acute exacerbation, or functional decline from those two or more chronic conditions. Many patients with clinically localized prostate cancer, for example, may not face those risks from their cancer.

A simple query based solely on diagnosis codes therefore may grossly overestimate the number of candidates for CCM. Ultimately, the billing physician is responsible for determining whether a patient is “at significant risk” and therefore eligible based on these guidelines.

Who can bill for CCM services in a urology practice? CMS clarifies that physicians, clinical nurse specialists, nurse practitioners, and physician assistants may all bill for CCM services. Billing done by non-physicians must be under the supervision of a physician and is subject to the “incident to” and general supervision guidelines.

Only one practitioner may be paid in any given month for CCM services; CMS anticipates that only one provider is performing those coordination services for any given patient at any given time. If, for example, a primary care physician refers a patient to a urologist for management of a urologic problem for whom the PCP is providing CCM services, the urologist could not also bill for CCM services during the same month. This may be prevented by a disciplined consent process and requiring the patient to formally acknowledge which of their physicians is providing the service.

Next: What does a CCM service entail and what are the documentation requirements?

What does a CCM service entail and what are the documentation requirements? After an initiating visit and consent from the patient, a CCM service is typically delivered outside of the office-for example, by phone call. A CCM service can be delivered with a frequency necessary for any given patient, but cannot be billed more than once per month for a single patient. The elements of that service include structured recording of health information in a certified EHR; development, maintenance, and sharing of an electronic comprehensive care plan with elements defined by CMS (bit.ly/Caremgt); 24/7 access to a caregiver; comprehensive care management that includes an assessment of medical, functional, and social needs, preventive care, and care coordination; and management of transitions of care (such as following hospital or ER care).

The provider billing for these services is expected to be the “quarterback” for the patient with significant chronic conditions-ensuring that the elements of the plan and ongoing management are followed and addressed.

Can CCM services be “outsourced” to a third party or service? In response to this question, CMS published this response: “Complex CCM… includes moderate to high complexity medical decision-making by the billing practitioner during the service period, an activity that cannot be subcontracted to any other individual. Similarly, regular (‘non-complex’) CCM… assumes 15 minutes of work by the billing practitioner. All CCM service codes are valued to include ongoing oversight, management, collaboration, and reassessment by the billing practitioner consistent with the included service elements. This work cannot be delegated or subcontracted to any other individual.

Read: CMS financial data: Who is getting paid what?

“A billing practitioner may arrange to have other aspects of the CCM service provided by clinical staff external to the practice (for example, in a case management company) if all of the ‘incident to’ and other rules for billing CCM to the PFS are met and there is clinical integration among the care team members,” the response continues. “If there is little oversight by the billing practitioner or a lack of clinical integration between a third party providing CCM and the billing practitioner, we do not believe CCM could actually be furnished and therefore the practitioner should not bill for CCM.” (bit.ly/CCMquestions).

This author recommends any urology practice that is contemplating outsourcing CCM services should obtain advice from qualified legal counsel.

Bottom line: Urologists may be the primary provider of care to patients eligible for CCM services and therefore eligible to bill for those services. Practices that are considering offering CCM services should understand the elements of the service-in particular the development and execution of an electronic care plan tailored to the needs of a patient-and whether they need additional resources to deliver that service. Finally, urologists should understand whether offering CCM services carries any benefit or risk to relationships with primary care physicians in their particular community, as only one physician can coordinate the care of these patients at any one time.

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