• Where can I find the revenue calculator?

    The Revenue Calculator can be found on Enli's dedicated CCM microsite.

  • Has there been any news regarding how long CMS will be reimbursing for this service? Is CCM being positioned as a temporary measure?

    CCM is discussed in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which relates policy and reimbursement beyond 2025. This, coupled with other indications of shifting reimbursement from volume to value, suggests that CCM is a permanent addition to the Medicare Physician Fee Schedule.

  • Do you have any sense of what percentage of eligible patients would engage in this type of service? Is there a benchmark for participation in CCM programs?

    The Center for Primary Care (CPC), featured in the webinar, estimates 75% of eligible patients will consent to participate in CPC's chronic care management program. Of those, they anticipate approximately 50% will remain compliant and meet the requirements to bill CMS.

    CPC provides one reference point for providers interested to forecast program impact. However, patient engagement rates can vary dramatically based upon a host of variables. For this reason, it is critical that providers have a deliberate strategy to educate beneficiaries and secure their consent. To discuss program modeling or for further information related to patient engagement, please contact us directly.

  • How do you identify high risk patients with larger volume of patients?

    Wake Internal Medicine, featured in the webinar, goes about it in a couple of ways. They first print an individual physician's entire Medicare patient panel, and then have the doctor and nurse review it for patients that can be easily identified (2+ chronic conditions, "frequent flyers", etc.). After this, Wake has clinical staff look ahead at schedules, flagging potential CCM candidates within the EHR where doctors and nurses can be prompted upon a patient's arrival for an appointment. It is then up to the doctor to dtermine if the patient qualifies and to subsequently offer a letter of consent to those who do.

  • We are still unsure about how to effectively "sell" the $8.00 copay to patients who question why they aren't already receiving that level of care coordination.

    Wake Internal Medicine presents CCM as a program that goes beyond routine, standard care by ensuring patients receive concierge style services. With enrollment, patients are carefully tracked and monitored, guaranteeing the most effective coordination of care with external providers and agencies. Patients are also provided with a channel for efficient communication with the practice. Wake has found it helpful to point out that CCM allows patients to engage their care team in a non-face-to-face manner (versus being asked to make an office based appointment to triage their inquiry or issue).

  • Are there specific documentation requirements for the 20 minutes of non-face-to-face services?

    The CCM regulations do not require a specific type of documentation of the 20 minutes of non-face-to-face services, nor has CMS issues any guidance on this issue. In the event a provider’s records were to be audited, having the start and stop time recorded for each service would provide the best defense to any challenge.  However, having the start and stop times for some services but not others would likely lead to additional inquiries from the auditors.  For this reason, the better practice is to document (1) the total amount of time spent, (2) the identity of the person providing the service, and (3) a brief description of the service rendered.  Again, CMS has not specifically required this level of documentation; this is instead a best practice to protect an organization in the event of any audit.

  • We have our first 8 patients enrolled, billed, and paid. However, patient engagement remains a challenge. Copays have been paid by secondary insurances, so cost should not be the barrier. How are you engaging your patients?

    Not all of Wake’s enrolled patients have been “success stories.” Most, however, have been. Having a care team that recognizes that some of the patients will require a little extra “TLC” and encouragement has been helpful. Patience and persistence can pay off when coupled with gentle education, reinforcement, and the rewards that come from compliance (i.e. med adherence, ER avoidance, and no unnecessary hospitalization). Over the long run, Wake must provide value to patients in order to retain their support. Different patients will perceive value from different types of CCM interactions. It also helps when the physicians are enthusiastic endorsers of an institution’s CCM program.

  • Can the time spent and documented by home health be counted toward the 20 minutes per month?

    If this time is part of an otherwise billable home health service, it cannot be applied or counted toward the 20 minute requirement. CMS would characterize this as “double-dipping.”

  • If you provide more than 20 minutes of non-face-to-face care during the month, can you bill for the extra time in the month that follows?

    CMS requires participating providers to deliver at least 20 minutes of non-face-to-face care to Medicare beneficiaries enrolled in CCM during a given month. Services must be delivered during that billing month and cannot be applied to future program months.

  • Does non face-to-face care need to be delivered "outside of the office"?

    Non-face-to-face care management services may be furnished inside or outside of the provider’s office. Clinical staff must perform these services under the general supervision of a physician. That physician, however, does not necessarily have to be the billing physician.

  • Would review of lab results and composing a letter outlining lab X-ray results satisfy this program?

    Additional guidance from CMS will be required to provide a definitive answer to this question. However, it appears from CMS’ commentary regarding CCM that this time could be applied toward the required 20 minutes, if performed by licensed clinical staff.

  • Do you feel a Certified Medical Assistant is qualified to do the assessment required by CMS to bill for this CPT code?

    CMS does not offer an opinion. Instead, they refer to the CPT definition of “clinical staff. ”Clinical staff is defined as a person who, under the supervision of a practitioner, is allowed by law, regulation, or facility policy to perform or assist in the performance of a specified action. Clinical competency should be determined by the physician in conjunction with state regulations, patient needs, etc.

  • Is a Medical Assistant allowed to make phone calls to beneficiary on behalf of and under the supervision of the doctor and does this count toward the 20 minutes of time (i.e. calling and making sure they are taking meds, going to their referral MD’s, etc.).

    Please see above.

  • Are Care Coordinators the same as a Registered Nurse or Medical Assistant?

    CMS does not specify. This is determined by the practitioners based on their perceptions of patient needs, staff capability, and practice protocols. In some states, there are regulatory scope of practice issues related to medical assistants that should be considered.

  • Have any of the practices assigned a specific physician within a large practice to be responsible for the patients being managed through the CCM process?

    No, the patient’s physician is responsible. Remember that much of this work is probably already being done by the primary care physician and associated staff. CCM is way to keep track of the work and obtain reimbursement.

  • Can we see the patient consent form? Also, does it need to be signed in person and how much does the patient have to pay to enroll in the program?

    PYA has developed a sample patient consent form. Please contact Enli directly if you would like to obtain a copy of the form.

    A provider cannot bill for CCM unless and until the provider secures the beneficiary’s written consent. A beneficiary must acknowledge in writing that the provider has explained the nature of CCM; how services can be accessed; that only one provider can furnish CCM; that the beneficiary’s health information will be shared for the purpose of care coordination; that the beneficiary may stop CCM at any time by revoking consent; and that the beneficiary will be responsible for any associated co-payment or deductible.

    Beneficiaries enrolled in a CCM program continue to be responsible for the standard copayment associated with Medicare Part B services, 20% or about $8 per month.

  • Can CCM be billed as “incident to”?

    This is a complicated question. CMS does not expect a physician to furnish all non-face-to-face care management services. Instead, the rules provide that licensed clinical staff may provide these services “incident to” the physician services. CMS recognized the direct supervision requirement of the “incident to” rules (i.e. physician present in the same suite of offices immediately available to provide assistance) was not practical for CCM and revised the regulations to provide for general supervision (i.e. available for telephonic consultation) for CCM (as well as transitional care management).

    Herein lies the problem: The "incident to" rules apply in the office setting only. only. “Incident to" billing is not permitted in the hospital inpatient or outpatient setting. If, for billing purposes, a hospital treats its employed physician practices as hospital outpatient departments, the question arises as to whether or not any time spent by licensed clinical staff can be counted toward the 20 minute requirement. If that time does not count, and all of those services must be furnished by the physician, it may be difficult to make the economics work.

    In direct communications with provider representatives (vs. public statements), CMS staff has clarified that a physician practicing in a hospital outpatient department who bills for CCM will be paid at the facility rate, which is approximately $9.00 less than the non-facility rate (i.e. the payment made to a physician practicing in an outpatient office setting). The payment to the physician reimburses him/her for supervision of hospital staff furnishing the non-face-to-face care management services, as well as any care management services furnished directly by the physician himself or herself.

    CMS also has clarified that a hospital may bill a separate facility fee for CCM. This payment reimburses the hospital for the costs associated with the licensed clinical staff furnishing the non-face-to-face care management services and related expenses.

    UPDATE 3/10/16: According to CMS, a service furnished “incident to” must be billed under the provider number of the physician (or non-physician practitioner) who supervised the individual providing the service. In the context of CCM, that would be the physician who supervised the clinical staff providing the non-face-to-face care management services. All other services furnished “incident to” require direct supervision, meaning the service has to be billed under the provider number of the physician/NPP who was physically present in the same suite of offices when the service were performed. With CCM, however, only general supervision is required – meaning the physician (1) is available (not immediately available, just available) by telephone or otherwise to address questions/concerns, and (2) is responsible for ensuring the clinical staff member providing the service is properly trained. No employment relationship is required. At the end of the day, I believe these CCM service providers can craft a contract that meets the requirements for “incident to” billing, i.e., allows the provider group to bill for the non-face-to-face care management services furnished by the CC service providers. It’s a matter of stating in the contract the provider group will furnish the appropriate level of supervision for the staff furnishing the non-face-to-face care management services, and then backing that up with appropriate processes.

  • Did I hear that Medicare Advantage (MA) plans will also be reimbursed?

    We are beginning to see MA plans issue coverage policies consistent with CMS. These have followed along several months (e.g., April) after the January 1, 2015 CCM date. It is unclear how MA plans with capitation or other shared risk arrangements will handle CCM, but we anticipate fee for service MA plans will reimburse in a fashion that is consistent with CMS.

  • Can time spent presenting to a group of patients with the same or similar issues count towards each patient’s monthly 20 minutes?

    CMS has not directly addressed this issue in any of its guidance.  Interestingly, CMS has stated on several occasions that if two individuals provide services for the same patient at the same time, only the time of one individual can be counted.  However, the agency has remained silent on the question whether the time spent by one person providing services to multiple patients at the same time can be counted for each of those patients.  Thus, I believe it is appropriate to bill that time for multiple patients, provided the service would not have been substantively any different if it had been provided one-on-one.

  • If a group practice has clinics enrolled in CPCI, can they participate in CCM and bill for it?

    According to CMS, practitioners participating in the Comprehensive Primary Care Initiative (CPCI) may bill Medicare for CCM services for those beneficiaries who are not attributed to the practices for purposes of participating in that demonstration project.

  • Can CCM be billed for and supported by specialists, as well as primary care physicians (provided a patient has not already signed up for CCM with another provider)?

    Yes, specialists can provide chronic care management services.  Specific specialties that seem to be actively exploring CCM include cardiology and oncology.

  • Do you have an example of what a care plan looks like?

    There is no standard care plan. It must reflect the specific needs of the patient. CMS has, however, identified the following as “typical” components of care plan:

    • Problem list, expected outcome and prognosis, and measurable treatment goals;
    • Symptom management and planned interventions, including all recommended preventive care services;
    • Plan for care coordination with other providers;
    • Medication management, including a list of current medications and allergies, reconciliation review of adherence and potential interactions, as well as oversight of patient self-management;
    • Responsible individual for each intervention;
    • Requirements for periodic review and revision.

    For the purpose of chronic care management, CMS suggests that the documentation generated through an annual wellness visit is similar to a care plan.

  • There seem to be different interpretations as to whether or not the care plan can be faxed. Can you please clarify this?

    CMS requires the provider have the capability to transmit the summary care record and the care plan electronically. CMS has stated facsimile transmission does not satisfy this requirement.

  • Do the requirements related to electronic access and transmission imply the need for a patient portal?

    There is no specific requirement that explicitly ties the provision of a patient portal to Medicare’s CCM program. However, there are requirements associated with Meaningful Use that directly relate to patient portals. Additionally, patient portals are understood to be one vehicle, among several, capable of helping to address or support certain CCM requirements that relate to the care plan and provider access.

  • Would you clarify the requirement about 24 x 7 accessibility?

    Generally, it means patients must be able to reach a member of the care team 24 x 7 for direction and support. For example, rather than leaving a message on an answering machine that directs CCM patients to the closest emergency room, practices should have a system that enables patients to discuss symptoms with a physician, or another care team member, in order to determine the most appropriate health intervention.

  • Assuming a provider meets all CCM requirements, are there any potential “audit fails” to be aware of?

    CMS has not yet established any claims edits for CCM. For now, there will not be automatic denials based upon date of service, site of service, or diagnosis codes. The only automatic denial would occur if another provider already had been paid for CCM for the same beneficiary for the same time period. In the event of a medical record audit, CMS (or the MAC or RAC auditor) most likely would look for the signed consent form, the electronic care plan, and documentation to support 20 minutes of non-face-to-face care management services furnished by licensed clinical staff.

  • During the demo, what product and version were we viewing?

    CareManager Central WorklistTM is a cloud-based, EMR agnostic application that can import patients from any system including CareManagerTM, Enli’s enterprise population health IT platform.

    DocuSign for PatientsTM, a HIPAA-compliant, digital signature solution was also demonstrated. It helps to facilitate electronic beneficiary consent.

  • What EMRs will CareManager interface with currently?

    CareManager Central WorklistTM is a cloud-based, EMR agnostic application that can import patients from any system including CareManagerTM, Enli’s enterprise population health IT platform.

  • Is the dashboard available on mobile devices?

    Central Worklist is not a mobile app, but does employ responsive design. This enables Central Worklist’s web UI to adapt based upon screen size.