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Medicare Mulls Changes to Boost Participation in Chronic Care Initiative

Kate Traynor

Kate Traynor News Writer
News Center

Few medical practices are embracing Medicare's year-old billing mechanism for chronic care management (CCM) services—and that has prompted the Centers for Medicare and Medicaid Services (CMS) to propose changes that may improve participation.

Current Procedural Technology (CPT) code 99490 was implemented in January 2015 to allow healthcare providers to bill for in-office and remotely delivered CCM services for patients with at least two chronic conditions that are expected to persist for at least a year and have potentially serious consequences.

CMS allows clinical care provided by pharmacists to count toward the monthly CCM services.

More than 55 million Americans were enrolled in Medicare last year. By some estimates, tens of millions of beneficiaries may be eligible for CCM services.

But according to CMS, last year just 275,000 Medicare beneficiaries received CCM services billed under CPT code 99490. The total claims amounted to an average of three visits per CCM participant, and CMS reimbursed healthcare providers a total of $37 million for the services.

In the July 15 proposed rule for the 2017 physician fee schedule, CMS acknowledged that CCM services are "underutilized."

The agency also stated that feedback on the program indicates that healthcare providers find the administrative requirements for implementing CCM services burdensome and redundant—and the reimbursement doesn't fully cover the cost of care delivery.

Twenty Minutes?

Healthcare providers are reimbursed about $42 per completed CCM encounter, and monthly claims may be submitted after 20 minutes of documented CCM services have been provided to the patient.

But healthcare providers say it routinely takes more than 20 minutes each month to provide CCM services to each patient—and there's no additional reimbursement for that time.

"In our experience, there's really no clean way to [end] these calls," said Derrick Hall, system director for complex and chronic care operations at Riverside Health System in Newport News, Virginia. "You want the patients to have what they need. You can't just cut the patients off at 20 minutes."

Riverside started a CCM pilot project in February at two practice sites and billed Medicare for about 260 CCM visits during the first six months of the project.

Hall said the pilot project was undertaken to "work out both the operational workflow kinks as well as the patient care kinks" before expanding CCM services to Riverside's approximately 30 primary care offices in eastern Virginia.

Hall said CCM calls during the pilot project "are running 35 minutes, on average."

He said Riverside expected that average call times would decrease as the staff gained experience and learned how to proceed more efficiently through the scripted elements, but that hasn't happened yet.

He also noted that office-based tasks required by CMS, such as the creation of patient-specific care plans, count toward the 20 minutes of monthly CCM services.

CMS appears to be aware that 20-minute CCM visits aren't sufficient.

In the proposed rule, the agency described two new CPT codes that would allow healthcare providers to bill for 30 or 60 minutes of complex CCM care. The proposal would limit claims to one of the three CCM CPT codes per patient each month, for a maximum of 60 minutes of care per patient.

The CMS proposal also eases some of the administrative, record-keeping, and electronic medical record (EMR) access requirements that may be contributing to low uptake of CCM services at primary care practices.

ASHP, in its official comments on the proposed rule, stated its support for the new CPT codes for complex CCM services.


Hall said one of the "tricky" aspects of providing CCM services is explaining to patients that the care is subject to a monthly copayment. The copayment is about $8—but that's only after the enrollee has met the annual Medicare deductible.

Early during the pilot program, Riverside had "a couple of angry patients" who hadn't met their deductible and were hit with unexpectedly high copayments for CCM services, Hall said.

"That was a place where we dropped the ball from a patient education standpoint. So we've made steps to correct that," Hall said.

Even some patients who have met their deductible are put off by the idea of paying a monthly fee for CCM services, Hall said.

"That's where the physician's messaging comes in," Hall said. "The way that we try to term it to our patients is, 'The doctor is using the term prescribing [in effect saying] 'Just as I would prescribe medication for you that would have a copay, I'm also prescribing this service for you.'"

Pharmacy's Role

 Hall said nurses provide most of the CCM services at Riverside's pilot project sites. But Riverside is making modifications to its EMR system to allow a clinical pharmacist to initiate and document the provision of CCM services.

For now, he said, when a medication-related question arises during a CCM call, the nurse contacts the pharmacist after the call and then relays the pharmacist-provided information to the patient.

Clinical pharmacy services are also part of the CCM package for some patients at CHI Franciscan Health in Tacoma, Washington, said Clinical Pharmacist Kara Crane.

Crane's CCM work mostly involves following up on medication-related concerns identified by a care manager during calls to patients.

"With our collaborative practice agreement, I am able to make recommendations and changes to therapy, if necessary," Crane said. "Between myself and the care manager, we are talking with the patients throughout the month. When we log the 20 minutes, then we notify the provider and they bill for it."

Eric Wymore, regional clinical pharmacy manager for CHI Franciscan Health, said the organization spent more than a year "working on workflows and optimizing the EMR to support this type of payment model."

"It's been challenging," Wymore said.

Timothy Lynch, division director and pharmacy officer, said CHI Franciscan Health considered having clinical pharmacists bill directly for CCM services but ultimately decided against it.

"We worked with our physician leadership and our compliance and revenue integrity team. And they felt that the billing really needed to stay with the physician...due to the way they interpreted the current requirements for submitting the bill," Lynch said.

"Our hope is to move to pharmacist billing for CCM services" in the future, he added.

But the CCM encounters have indirectly generated additional opportunities to bill for clinical pharmacy services at CHI Franciscan.

"For the patients I have been involved with, there's often a lot more need to help them other than just talking to them on the phone," Crane said. "That generates a referral, where I bring the patient in and see them face to face and address specific concerns [about] their medications or their disease state."

Those independent visits are billed as evaluation and management services provided incident to a physician's care, generally using CPT code 99211. And because pharmacists in Washington are recognized as healthcare providers, they can bill both Medicare and private insurers using CPT code 99211.

Overall, Lynch said, the increased visibility of clinical pharmacists' work has created new opportunities within the health system.

"We have had tremendous requests for growth and expansion of our services as a result of the work that Kara and other team members have done," Lynch said. "As successes are shared among the physicians throughout the organization, our clinic leaders are coming forward and requesting that they have a pharmacist embedded within their care model."

[This news story appears in the Nov. 15, 2016, issue of AJHP.]

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