mation. Among other program ele- ments, practices must be able to offer:
• Structured recording of patient health information;
• 24/7 access to care that gives pa- tients a way to make timely con- tact with someone in the practice who has access to the patient’s care plan;
• Facilitation of care transitions be- tween settings, including referrals, and follow-up after hospital dis- charges and emergency visits;
• Prescription management and rec- onciliation; and
• Care coordination in and outside the practice, for example, with spe- cialists, and home and community- based services.
The code allows practices to bill
for documented non-face-to-face care management and coordination activi- ties that consume at least 20 minutes of staff time per month, either all at once or incrementally. Other billing requirements weave a web of rules practices must follow closely to get paid:
• Practices can bill the code only once per calendar month;
• Only one clinician at a time can provide and bill for CCM services; and
• Practices cannot bill for certain other codes during the same month as they bill for CCM services: tran- sitional care management (TCM) and certain services for home health, hospice, and end-stage re- nal disease.
Medicare relaxed certain “incident
to” billing rules that normally would require physicians to be on site to di- rectly supervise chronic care services provided by other licensed clinical staff, which can include nurse prac- titioners, physician assistants, and medical assistants. But Medicare still requires some
cost-sharing from patients, who must pay a monthly copay of about $8, or 20 percent. TMA officials warn routinely waiving patient copays is illegal under state law and could invite a Medicare investigation. (For more details, read this TMA Practice E-Tip at tma.tips/ copaywaiver.)
CALCULATED RISK Financial incentives in the CCM pro- gram can be substantial. (See “Run- ning the Numbers,” below.) Still, TMA leaders acknowledge it may require an equally significant investment and commitment from practices to adapt workflow or create the infrastructure needed to reap the rewards. For instance, Mr. McCormick says
those already on the path to becoming a medical home or joining an ACO — whose requirements generally overlap
— may have an easier time. “Practices are going to have to evaluate where they are on the spectrum of providing value-based care, and the question is: Can we take this on by ourselves, or do we need help?” On the other hand, even as Medi-
care pursues an overall value-based care strategy, Dr. Salman highlights the CCM program is available to all primary care practices, regardless of size, and doesn’t require medical home recognition or participation in an ACO.
“Primary care physicians are best positioned to deliver this service, and size doesn’t matter. What matters is,
150 $42 12 $75,600
RUNNING THE NUMBERS x
patients with 2 or more
chronic illnesses *Average, subject to regional variation September 2015 TEXAS MEDICINE 47
monthly CCM payment*
x months =
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