Pharmacy Practice

CMS Expands Medicare's Chronic Care Management Services

Cheryl Thompson
Cheryl A. Thompson Director News Center Published: January 25, 2018

Federally qualified health centers and rural health clinics can now be paid by Medicare for providing care coordination services similar to the complex chronic care management services for which physician offices have been billing the federal health plan since 2017.

The change, part of the 2018 update by the Centers for Medicare and Medicaid Services (CMS) to the physician fee schedule, means a nationwide payment of $62.28 per calendar month for providing at least 20 minutes of care coordination services to a patient with multiple chronic conditions, a behavioral health condition, or a psychiatric condition.

This payment can be in addition to Medicare’s per-visit payment to the health center or clinic and does not require a face-to-face meeting with the patient after the initiating visit.

And the time that pharmacists, as “auxiliary” personnel, spend providing the care coordination services counts toward the monthly minimum time, CMS stated in a November 2017 FAQ.

New Services Term, Billing Code

ASHP, in commenting on proposed updates to the physician fee schedule, expressed to CMS its support for the creation of a billing code that recognizes the complexity of coordinating the care of patients at federally qualified health centers and rural health clinics.

Chronic care management services, which include medication management and reconciliation, became a Medicare-payable service for these providers in 2016.

They had to furnish at least 20 minutes of the services during a calendar month in order to use Current Procedural Terminology (CPT) code 99490. The nationwide payment rate in 2016 was $40.82.

Eligible patients had to have multiple chronic conditions. Mental health conditions counted toward the minimum of 2 chronic conditions.

In 2017, Medicare started paying physician offices for CPT codes denoting chronic care management services that required moderate- to high-complexity medical decision-making and additional time. Chronic care management services not requiring that level of medical decision-making and associated time commitment became known as “non-complex.”

Because Medicare does not pay federally qualified health centers and rural health clinics for individual services and on the basis of time, CMS said it would find a means other than CPT codes to recognize those providers’ provision of care coordination services.

The result is general care management code G0511.

The payment rate for code G0511 is the average of the rates for 3 services provided at physician offices where Medicare does not make a separate payment to cover supplies, equipment, and the clinical staff. Those 3 services are (1) chronic care management for at least 20 minutes per calendar month, (2) complex chronic care management for at least 60 minutes per calendar month, and (3) behavioral health integration for at least 20 minutes per calendar month.


Auxiliary Personnel

To clarify the level of supervision required over personnel involved in certain care management services, CMS changed the federal regulation on services provided incident to a physician’s care.

Gone since January 1, 2017, is the statement referring to “clinical staff,” which the regulation on such incident-to services did not define. Lacking a regulatory definition, CMS had deferred questions about who qualified as clinical staff to the agency’s Medicare administrative contractors [see April 1, 2015, AJHP News].

The regulation on incident-to services now reads in part: “Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner). The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly.”

Auxiliary personnel, the regulation states, act under the supervision of a physician or other practitioner, meet the state’s requirements for providing services incident to a physician’s care, and can be employees, leased employees, or independent contractors.

Complex Chronic Care Management Services

Billing Medicare for complex chronic care management services has been relatively infrequent but not a problem, said Paige Carson, clinical team leader for pharmacists in the care management program at Carolinas HealthCare System.

The healthcare organization, based in Charlotte, North Carolina, runs regional hubs where care management team members work to keep the medical practices’ patients who have a high risk of hospital readmission or uncontrolled diabetes mellitus “healthy and out of the hospital and able to self-manage,” Carson said.

Pharmacists already were on the teams, conducting in-person comprehensive medication reconciliations and communicating with patients about medication-related issues, when Medicare started allowing physician offices to bill for chronic care management services, she said. All 8 pharmacists working in care management have the state’s clinical pharmacist practitioner, or CPP, credential.

Once eligible patients consent to receiving chronic care management services, which have a per-month copayment, Carson said, the patients are classified as service recipients in the electronic health record.

The pharmacist, nurse care manager, and health advocate on each team routinely log their “communication events,” including time spent performing various functions, into the electronic health record, she said. That data is tracked for all the Medicare beneficiaries whose record indicates they receive chronic care management services, which she estimated at 10–20% of the patients in the care management program.

“If the minutes are very high, above 60 minutes per [calendar] month, then we double-check and make sure that the care plan has been modified for the patient,” Carson said.

The descriptor for the CPT code designating complex chronic care management services includes the requirement for “[e]stablishment or substantial revision of a comprehensive care plan.”

“As long as that’s documented and the notes are in the electronic health record,” Carson said, Medicare is charged for the higher-paying service.

[This news story appears in the February 15, 2018, issue of AJHP.]

Posted January 25, 2018

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