• linkedin
  • Increase Font
  • Sharebar

    You can deliver chronic care services; here’s how

    Querying practice management/EHR database may help screen for potential patients

    Robert A. Dowling, MDRobert A. Dowling, MDIn 2015, the Centers for Medicare & Medicaid services (CMS) began separately paying for the chronic care of patients not conducted in face-to-face encounters with a fee schedule service known as “Chronic Care Management” (CCM) (bit.ly/Caremgt). Predicated on the belief that Medicare patients with multiple chronic conditions have opportunities for better care, CMS created this category of service to reimburse physicians and their staff for coordinating that care—outside of an office visit. CMS contemplated that CCM services would be billed most frequently by primary care practitioners but also wrote, “in certain circumstances, specialty practitioners may provide and bill for CCM.”

    Some urology practices may be contemplating delivering CCM services to eligible patients, and this article will answer key questions about the program and features to consider when making that decision.

    What type of patients are eligible for CCM, and are they found in your urology practice? CMS defines an eligible patient as having “multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.” While there is no inclusive list of chronic conditions, guidance from CMS can be found in its reference to the 19 conditions for which CMS tracks utilization and appending information (bit.ly/CMSchronicconditions).

    Also by Dr. Dowling: How will urologists fare under 2018 MIPS rule?

    It is likely that many patients in a urology practice have two or more of these conditions, and a simple query of a practice management or electronic health record database might be the first step to screen for these potential patients. Other chronic conditions not on this list could potentially include bladder cancer or kidney cancer. It could even be argued that urinary retention or incontinence is a chronic condition. To be eligible, though, the patient must also be at significant risk of death, acute exacerbation, or functional decline from those two or more chronic conditions. Many patients with clinically localized prostate cancer, for example, may not face those risks from their cancer.

    A simple query based solely on diagnosis codes therefore may grossly overestimate the number of candidates for CCM. Ultimately, the billing physician is responsible for determining whether a patient is “at significant risk” and therefore eligible based on these guidelines.

    Who can bill for CCM services in a urology practice? CMS clarifies that physicians, clinical nurse specialists, nurse practitioners, and physician assistants may all bill for CCM services. Billing done by non-physicians must be under the supervision of a physician and is subject to the “incident to” and general supervision guidelines.

    Only one practitioner may be paid in any given month for CCM services; CMS anticipates that only one provider is performing those coordination services for any given patient at any given time. If, for example, a primary care physician refers a patient to a urologist for management of a urologic problem for whom the PCP is providing CCM services, the urologist could not also bill for CCM services during the same month. This may be prevented by a disciplined consent process and requiring the patient to formally acknowledge which of their physicians is providing the service.

    Next: What does a CCM service entail and what are the documentation requirements?

    Robert A. Dowling, MD
    Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality ...


    You must be signed in to leave a comment. Registering is fast and free!

    All comments must follow the ModernMedicine Network community rules and terms of use, and will be moderated. ModernMedicine reserves the right to use the comments we receive, in whole or in part,in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.

    • No comments available