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New Rule on Medicare Reimbursement for Chronic Care Management Services

In November 2014, the Centers for Medicare & Medicaid Services (“CMS”) issued a final regulation with changes intended to ensure Medicare’s payment system “reflect[s] changes in medical practice and the relative value of services, as well as changes in the statute.” One of the beneficial changes for physicians is the new Medicare reimbursement of chronic care management (“CCM”) services, which began with the New Year on January 1, 2015. All providers should pay special attention to the essential requirements for chronic care management reimbursement and begin identifying eligible fee-for-service Medicare patients.

The new CCM provisions are designed to pay for services that many practitioners are already doing – managing patient care and continuity of care through follow up care and case management after a patient visit and outside of a face to face visit. Providers will now receive monthly payment for at least 20 minutes of clinical staff CCM time for Medicare patients with multiple significant chronic conditions as long as the CCM care is directed by a physician or other qualified health care professional. The reimbursement rate for these non-face-to-face services is $42.60 (an RVU of 0.61 with 20 minutes of clinical staff time) and providers should bill under the new CPT code of 99490 once per month. CMS touts this new CCM coverage as part of an initiative to improve access to primary care for Medicare beneficiaries. The use of CCM will also enhance continuity of care and hopefully reduce hospital readmissions for Medicare patients with chronic conditions. The high rate of hospital readmissions for Medicare patients with chronic health conditions drives up healthcare costs and Medicare covers a large population with multiple chronic health conditions.

The final regulations also provide some flexibility in the supervision of clinical staff providing CCM services. Before this regulation, clinical staff had to be under the direct supervision of the practitioner, which meant that the practitioner had to be in the office suite and available to provide assistance, for the clinical staff’s service time to be reimbursed as furnished “incident to” a practitioner’s professional service. In contrast to the prior reimbursement policy, the new regulation recognizes that the increased need for round-the-clock access to CCM means that direct practitioner supervision is not always feasible. As a result, the final regulations merely ask for “general,” as opposed to “direct,” supervision of the clinical staff for the provision of CCM services after business hours. Although the clinical staff still must be direct employees of the practitioner or practice, CMS requires less practitioner supervision of the clinical staff’s CCM services, which gives providers some breathing room in the supervision of these services.

The potential downside to the new CMS rule is that practitioners wishing to bill CMS for qualified CCM services must adhere to certain standards for their electronic health records (“EHR”) systems. The EHR systems must be certified under the terms of the EHR Incentive Payment Program that picked up in 2011 as a result of the American Recovery and Reinvestment Act. Providers wishing to bill for CCM services must use EHR systems that were certified as of December 31st of the prior year. As a practical result, this means that both 2011- and 2014-certified EHR systems are currently acceptable. While this slightly-softened rule benefits many current providers, some providers will have to invest in updating their EHR system in the future, and this may have a significant cost.

© 2019 by McBrayer, McGinnis, Leslie & Kirkland, PLLC. All rights reserved.


About this Author

Emily M. Hord, Health Care Attorney, McBrayer Law Firm

Emily M. Hord is an Associate of McBrayer, McGinnis, Leslie & Kirkland, PLLC. Ms. Hord concentrates her practice in healthcare law and is located in the firm’s Lexington office. Ms. Hord has experience in a variety of health law issues. She has represented hospitals and healthcare networks, physicians and other medical professionals, nursing homes, and private physician practices. She provides services in the following areas: regulatory and statutory compliance, Certificate of Need and licensing, professional license defense, employment contracts for medical professionals, HIPAA...