Frequently Asked Questions

What does Medicare reimburse for CCM?

Effective June 1, 2015, the national average reimbursement is $43.00 PM/PM

Is CCM exempt from Beneficiary cost sharing?

No. Beneficiaries are responsible co-payment or deductible amounts. For Beneficiaries with a Medicare Supplemental Insurance policy (Medi-Gap), co-pays and deductibles are covered like co-pays and deductibles for office visits.

What Beneficiaries are eligible to receive CCM?

Any Medicare Enrollee who has been diagnosed with 2 or more chronic conditions expected to persist at least 12 months (or until death) and that cause the Beneficiary to be at significant risk of death, acute exacerbation/decompensation, or functional decline.

Does CMS recognize a specific list of chronic conditions?

At a minimum, all of the conditions listed in the CMS Chronic Condition Warehouse are qualifying conditions however additional conditions may also be recognized as eligible when determining eligibility for CCM.

Which Providers may bill Medicare for CCM?

Physicians (any specialty), Advanced Practice Registered Nurses, Clinical Nurse Specialists, Physician Assistants and Certified Nurse Midwives.

Can more than one Provider bill for CCM for the same Beneficiary?

No. Only one claim for CCM per Beneficiary per calendar month will be paid by Medicare.

What services does a Provider have to provide a Beneficiary before billing for CCM?

CMS recommends that a Provider furnish an annual wellness visit (AWV) (HCPCS G0438, G0439) or an initial preventive physical exam (IPPE) (G0402) to the Beneficiary, however there are no prerequisite services required to bill for CCM.

Are there services a Provider cannot bill in the same calendar month they are billing for CCM?

Yes, there are four-home healthcare supervision (HCPCS G0181), hospice care supervision (HCPCS G0182), certain end-stage renal disease services (CPT 90951-90970) and transitional care management (CPT 99495 and 99496); however, where TCM is concerned, CCM can be billed by the same Provider in the same calendar month and for the same Beneficiary provided the 30-day post-discharge service period for TCM ends prior to the end of the calendar month, and 20 minutes of CCM is provided after the conclusion of TCM and before the end of the month. If the Provider of CCM delivers any other services for the Beneficiary the provider can bill for that service in addition to billing for CCM.

Is CCM recognized as a (FQHC) Federally Qualified Health Center or (RHC) Rural Health Center service?

CMS does not recognized CCM as an FQHC or RHC service and these Providers will not be reimbursed at their all-inclusive rate for CCM services. An FQHC or RHC may be able to bill for CCM on the Medicare Physician Fee Schedule if it satisfies the all requirements to bill for non-FQHC/ non-RHC services.

Can Medicare Shared Savings Program (MSSP) participants bill for CCM?

Multi-Payer Advanced Primary Care Practice Demonstration and Comprehensive Primary Care Initiative participants may not bill CCM for Patients attributed to them under those programs.

Do Medicare Advantage and commercial insurance plans reimburse for CCM?

Medicare Advantage plans are required to offer all traditional Medicare benefits, which CCM now is. Accordingly, it’s expected that Medicare Advantage plans will begin paying for CCM. Commercial payers will or will not at their own discretion.

What must a Beneficiary consent/ acknowledge prior to receiving CCM services?

Providers cannot bill for CCM without a Beneficiary’s written consent. A Beneficiary must acknowledge in writing their Provider has explained the nature of CCM; how CCM is accessed; that only one Provider at a time can be their CCM Provider; that their health information will be shared with other Providers to coordinate their care; that they may stop CCM at any time by revoking consent, and that they are responsible for co-payments or deductibles.

When and how must Beneficiary consent be obtained?

Consent must be obtained prior to beginning CCM. When obtaining written consent for CCM, the billing Provider should utilize their existing policies regarding obtaining consent for treatment. For a Beneficiary deemed incompetent, the consent form should be signed on the behalf of the Beneficiary by a legal guardian and/or per state law regarding evidencing medical treatment consent.

What happens if a Beneficiary revokes his or her consent?

If a Beneficiary revokes their consent from their provider of CCM, CCM services may not be billed for that Beneficiary after that current calendar month. The Provider can bill for CCM delivered during the month of revocation if the Provider has completed the minimum 20- minutes of non-face-to-face care management required.

What five capabilities does CMS require a billing CCM provider to have?

  1. Use a CCM certified EHR.
  2. Maintain electronic care plans.
  3. Ensure a Beneficiary’s access to care.
  4. Assist Beneficiaries in transitions of care
  5. Provide care coordination.

How must a Provider use a CCM Certified EHR in furnishing CCM?

A Provider is required to use “CCM certified technology” or an EHR that meets the 2011 or 2014 edition of the certification criteria for the EHR Incentive Program and which has certain core technology capabilities which includes:

  1. Structured recording of demographics, medications, and medication allergies, and problems.
  2. The ability to create summary care records.
  3. The ability to transmit the summary care record electronically as a part of the care coordination process (Facsimile transmission does not meet this criteria).

The CCM certified technology must be used to document Beneficiary consent, provide the care plan to the Beneficiary and for communications to and from home and community-based providers regarding the Beneficiary’s functional deficits and psychosocial needs.

What is the electronic care plan requirement?

A Provider must develop and update (at least annually) an electronic care plan based on assessment of the Beneficiary’s physical, mental, cognitive, psychosocial, functional, and environmental needs. This care plan should include the list of current Providers regularly involved in providing care to the Beneficiary, an assessment of functional status related to the Beneficiary’s chronic conditions, an assessment of cognitive limitations and/ or mental health conditions and an assessment any preventive healthcare needs the Beneficiary may have. The plan should address health issues globally (not just the Beneficiary’s chronic conditions) and evidence the values and choices of the Beneficiary. The preparation and updating of this care plan is reimbursable under the CCM CPT 99490. These activities may be billed separately as evaluation and management service (e.g., an AWV, an IPPE) or as a regular office visit provided all applicable requirements are met.

Who needs access and how may they access the electronic care plan?

CMS specifies three requirements:

  1. The care plan must be electronically accessible on a 24/7 basis to all care team members furnishing CCM services billed by the Practitioner.
  2. The Provider must electronically and securely share care plan information with other Providers of the Beneficiary.
  3. The Provider must make available either a paper or electronic copy of the care plan to the Beneficiary yet the same must be documented in the Provider’s CCM certified technology.

What is required with respect to Beneficiary access to care?

A provider of CCM must:

  1. Provide for the Beneficiary to access a member of the care team 24/7/365 to address acute and urgent needs.
  2. Ensure the Beneficiary is able to get successive routine appointments with the billing Provider or a member of their care team.
  3. Provide enhanced opportunities for Beneficiary-Provider communications by telephone and other methods (Example: Secure email/ messaging). The Beneficiary is not required to use these methods however.

What does it mean to provide transitions of care?

A Provider must:

  1. Follow-up with the Beneficiary after an ER visit.
  2. Provide post-discharge TCM services (Transitional Care Management) when necessary; notwithstanding a Provider may not bill for CCM and TCM in the same month.
  3. Coordinate referrals with other Clinicians.
  4. Share information electronically with other treatment team members.

What is required to demonstrate coordination of care?

Providers must be able to coordinate with home and community based (HCBS) service providers in a fashion that meets the Beneficiary’s functional deficits and psychosocial needs (Example: home health and hospice providers, outpatient therapy providers, durable medical equipment providers, and transportation and nutrition services). Communication with these ancillary service providers must be documented in the provider’s CCM certified technology.

What types of services constitute billable, non-face-to-face CCM services?

CMS identifies the following types of services performed as counting toward the 20-minute requirement:

  1. Medication reconciliation and monitoring a Beneficiary’s medication self-management.
  2. Ensuring receipt of recommended preventive services.
  3. Monitoring a Beneficiary’s condition (physical, mental, social. Other types of services may also count toward the 20-minute requirement.

For example, CMS identified the following additional services as additional non-face-to-face care management services that qualify as CCM services:

  1. Providing education.
  2. Addressing questions from a Beneficiary, their family, guardian, and/or caregiver(s).
  3. Identifying and arranging needed community resources.
  4. Communicating with home health agencies and other providers used by a Beneficiary.

Who may perform CCM services?

Clinical staff will provide CCM services incident to the services of the billing Physician or the non-Physician Practitioner. However, if the billing Practitioner provides these services directly, that time also counts toward the 20-minute minimum. CMS references that the definition of “clinical staff” is a person working under the supervision of a Physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service. CMS stipulates that time spent by clinical staff may only be counted if Medicare’s “incident to rules” are met, which includes   supervision, applicable State law, licensure and scope of practice. It is the responsibility of the billing Practitioner to determine that clinical staff is competent and capable of performing any specific services with appropriate supervision. Additionally, CMS notes that other staff may help facilitate CCM services, but only the time spent by clinical staff may be counted towards the 20- minute time requirement for billing. CMS further permits the billing Provider to arrange for clinical staff external to the practice (Example PCCM, LLC) to provide the non-face-to-face care CCM services for the Provider’s Patients, but only if all requirements for “incident to” billing are satisfied, including general supervision.

What level of supervision is required for staff providing non-face-to-face CCM services?

CMS requires only “General Supervision” (Physician or other provider available by telephone to provide assistance as required). Accordingly, the Physician or other Provider does not have to be the same person under whose name CCM is billed. Thus, a Provider may contract with a third party to provide non-face-to-face CCM services provided the third party has electronic access to the Beneficiary’s care plan. Thus “subscription service” for CCM is permitted.

What type of documentation is required to bill for CCM?

At a minimum:

  1. The date and amount of time spent providing non-face- to face services during the month.
  2. The name and credentials of the clinical staff providing services.
  3. A brief description of the services provided.

What and how may time be counted toward the 20-minute minimum monthly requirement?

Time spent in the aggregated may be accumulated throughout the month. For example, services provided on different days and/or by different clinical staff members may be aggregated to a total 20 minutes. Same said, where two staff members provide the same service simultaneously, only the time spent by one staff member may be counted. Time spent may not be rounded up to meet this requirement or carried over from a prior month.

Can CCM services be provided on the same day an office visit is provided a Beneficiary and still count toward the 20-minute minimum monthly total?

Time appropriately considered part of the E/M service cannot be counted as a part of CCM allocated time, but separate time spent by clinical staff providing non-face-to-face services specifically associated with CCM may be counted. Where both an E/M and the CCM code are billed on the same day, a 25 Modifier will need to be added on the CCM claim.

May CCM services be provided an inpatient Beneficiary?

CCM cannot be billed for a Beneficiary who is inpatient at a hospital or skilled nursing facility. If the Beneficiary is not inpatient all month, time spent providing CCM services while the Beneficiary is not inpatient can be counted toward the 20-minute requirement for that month.

Can monitoring/ telemetry be counted as part of the 20-minute minimum requirement?

Providers remote monitoring a Beneficiary’s physiological data may count the time they spend reviewing the monitoring data toward the 20- minutes required to bill for CCM but they may not count the time a Beneficiary spends being monitored. To bill CPT 99490, reviewing monitoring data may not be the only work being done as all other aspects of the CCM requirements must be met.

What should be listed as the date of service on a CCM claim?

Providers may list the date of service as the day the 20-minute minimum requirement is met or any day thereafter and prior to the end of the calendar month.

What should be listed as the place of service?

The Provider would list the location where they would normally provide a face-to-face office visit for the Beneficiary.