Chronic Care Management Frequently Asked Questions

Below are some frequently asked questions about the chronic care management program.

Question: Is there a list of chronic conditions that qualify for this service?

Answer: CMS doesn’t really specify a list of conditions or diagnosis codes, but conditions like diabetes, hypertension, or asthma, will serve to meet the requirements.

Question: What kind of services qualify as care management?

Answer: Some examples of chronic care management include:

  • Medication reconciliation, including adherence and potential interactions
  • Overseeing patient self-management of medications
  • Managing care transitions between and among health care providers and settings, including referrals to other providers, such as specialists
  • Providing follow-up care after an emergency department visit and after discharges from other settings
  • Coordinating care with home and community-based clinical service providers

Question: Who can provide these services?

Answer: Any clinical staff member can provide these services. However, time spent by non-clinical staff such as a receptionist cannot be counted toward the time requirement.

Question: If multiple members of a practice’s staff are providing these services, who can bill the code?

Answer: CMS is very specific about this: only Physicians, Certified Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners, and Physician Assistants can bill the CCM code. And only one clinician may be paid for the CCM service in a given calendar month. The general rule of thumb is that a Medicare beneficiary’s primary provider in the practice should be the one billing this code.

And there are several codes that cannot be billed in the same service month as the CCM code, including the Medicare Care Transitions code, home health care supervision or hospice codes, and certain End-Stage Renal Disease services.

Question: What is required to bill for CCM services?

Answer: To bill for CCM, CMS requires practices to provide:

  • 24/7 access to address the condition
  • Continuity of care with a provider the patient can see routinely
  • Systematic assessment of the patient’s needs
  • A well-documented care plan
  • Care transition management
  • Enhanced patient communication options — beyond the phone

Question: Since one provider can bill the code per month, which provider should be the one billing the code, Primary Care providers or Specialists?

Answer: CMS expects the CCM code to be billed most frequently by Primary Care physicians, although they say that specialists who meet all of the billing requirements may bill for the service.

Question: What is the reimbursement for the CCM code?

Answer: The national average reimbursement for the CCM code is $42.91 per beneficiary per month. It’s important to remember that patient cost-sharing applies to the CCM code, so patients may be billed for a co-pay, approximately $8-$10.

Question: What are the other requirements for CCM services?

Answer: CMS requires that the billing provider furnish a comprehensive evaluation and management visit, Medicare Annual Wellness Visit, or Initial Preventive Examination prior to billing the CCM code AND that the CCM service be initiated as part of this visit. Medicare requires that eligible patients be informed of the availability of the CCM code and that the provider obtains written consent from the patient to have the services provided. In addition, the patient must authorize electronic communication of his or her medical information with other providers.

The clinician must explain and offer the CCM code to the patient and document this discussion in his or her medical record, noting the patient’s decision to accept or decline the service. Plus, the clinician must explain how to revoke the service and that only one practitioner can provide and be paid for the service during a calendar month.

The provider must create a care plan based on a comprehensive assessment of the patient, provide the patient a copy of the care plan, ensure that the plan is available electronically at all times to anyone within the practice providing the CCM service, and share the care plan electronically outside the practice as appropriate.

Question: What is included in a Comprehensive Care Plan?

Answer: Here are some examples that CMS gives:

  • A patient’s problem list
  • Measurable treatment goals
  • Medication management
  • A description of how services of community agencies and specialists outside the practice will be directed/coordinated

These are just a few examples but there are many more options for clinicians to choose.

Question: Does the care plan need to be captured in the software?

Answer: Yes, CMS mandates that the Care Plan be captured electronically in the EHR. In addition, the provider needs to have the patient’s demographics, problem list, medications, and allergies documented in the EHR and be able to create a clinical summary.

Question: After creating the care plan, what CCM services are provided?

Answer: Since the requirement is at least 20 minutes of care management services provided per month, providers must be documenting the time involved in each episode of care. Some EHR vendors have devised ways of keeping track of time.

Regardless of the mechanism, there are several elements that should be logged for each instance of care management, some of these elements are: chronic

  • The date the services were provided
  • The name of the staff member providing the services
  • The time spent providing the services
  • Details on the services provided

Question: What happens if the patient contacts the provider after hours?

Answer: CMS requires that the patient has 24 hours/day, 7 days/week access to care management services, so the practice needs to ensure that the patient can make timely contact with other health care practitioners in the practice who can access their electronic care plan in order to address his or her urgent chronic care needs. Any provider whose time spent providing care management services counts toward the 20 minute requirement must have electronic access.

Question: Does CMS mandate specific ways in which the CCM services are provided?

Answer: Yes, providers must provide enhanced opportunities for the patient and their caregivers to communicate regarding the patient’s care. This can be through the telephone, secure messaging, secure Internet, or any other non-face-to-face consultation.


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