CCM Final Rule

Chronic Care Management

On Wednesday, November 2, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule updating payment policies and rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2017. CMS also finalized a number of new PFS policies to improve Medicare payment and patient management for those services provided by primary care physicians, including chronic care management (CCM).

Background

Historically, CMS has “bundled” CCM into the evaluation and management (E&M) visit codes used by all specialties. Thus, CCM payments have been distributed equally among specialties that report E&M codes, rather than targeted toward providers who primarily manage chronic conditions. In recent years, CMS created new codes that separately pay for CCM services.

After considering public comments on CCM policies, CMS is finalizing a number of coding and payment changes for CY 2017 to better identify and value CCM services as well as improve provider payment for those investing in time and resources to provide more coordinated, patient-centered care. The final rule also finalized and defined CCM elements and billing requirements.

Coding and Payment

  • CCM Common Procedural Terminology (CPT) codes for CY 2017 include: * CPT code 99487, complex CCM (60 minutes), $93.66; * CPT code 99489, complex CCM (additional 30 minutes), $46.87; and * CPT code 99490, CCM services (20 minutes), $42.22
  • Renders separate payments for certain existing Current Procedural Terminology (CPT) codes
    describing non-face-to-face prolonged E&M services.
  • Revalues existing CPT codes describing prolonged face-to-face services.
  • Makes separate payments via a new code to describe comprehensive assessment and CCM
    services and planning for cognitively impaired patients.
  • Establishes separate payments for codes describing CCM for patients with greater complexity.

Selected CCM Service Elements

  • Records demographics, diagnoses, medications, and other variables using certified electronic health record technology (CEHRT) to inform the beneficiary’s care plan and coordinate ongoing clinical care.
  • Provides continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments.
  • Manages care for chronic conditions including systemic assessment of the beneficiary’s medical, functional, and psychosocial needs.
  • Requires complex CCM services include medical decision-making of moderate to high complexity by the physician or other billing practitioner.
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