Can My Hospital Bill Medicare for Telehealth Chronic Care Management?

15 July 2015 Health Care Law Today Blog

In a word: yes, and CMS just introduced proposed rules to clarify the requirements and payment opportunities when hospitals want to bill Medicare for Chronic Care Management (“CCM”) services.

CCM is an exciting service covered by Medicare and perfectly suited for telehealth, as CCM may be provided via remote care services. CCM is another way hospitals can harness telehealth technology to leverage staffing, improve patient care, increase doctor-patient contact, decrease inpatient length of stay, and ultimately reduce overall patient costs. The CCM billing code, which pays providers on a monthly capitated (per patient per month) basis, went live January 1, 2015.

Hospitals offering outpatient CCM services may bill Medicare under the Outpatient Prospective Payment System (“OPPS”) for the facility portion of the service. In addition, Medicare will pay for the physician/practitioner time directing the CCM services under the Physician Fee Schedule.

On July 1, 2015, CMS issued its CY 2016 proposed OPPS rule explaining in greater detail the requirements hospitals must meet to take advantage of the CCM billing opportunity. The proposed rule followed a set of CCM billing FAQs released in May 2015.

Hospitals billing CPT 99490 should continue the established practices set forth in the CY 2015 final rule. Namely, they must deliver CCM clinical services at a minimum of twenty minutes per month, per patient; eligible CCM patients must have two or more chronic conditions; and care plans are required. The proposed rule also notes the following requirements for OPPS billing:

  • The patient must have been admitted to the hospital as an inpatient or a registered outpatient, and the hospital must have provided therapeutic services.
  • Hospital services must be documented in the medical records; the CCM services must be both explained and offered to the patient; and the patient’s decision to accept or decline treatment must be documented.
  • Only one hospital is eligible per month to provide and bill for services under CPT 99490.

The rule also proposes ten additional requirements for OPPS payment (these requirements are analogous to those in the Physician Fee Schedule under the CY 2015 final rule).

  • Hospitals must create a structured clinical summary record and document the patients demographics, problems, medications, and medication allergies. The patient’s care plan, care coordination, and ongoing clinical care must be informed by the full list of problems, medications, and medication allergies in the electronic health record.
  • Hospitals must provide patient access to CCM services 24/7.
  • Hospital OPPS departments must provide consistent care to CCM patients through a designated practitioner or member of the care team who facilitates successive routine appointments.
  • CCM services must include systematic assessments of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation and a review of the patients adherence and potential interactions and oversight of patient medication self-management.
  • Hospitals must document the production of a comprehensive patient-centered care plan. The plan will build on a physical, mental, cognitive, psychosocial, functional and environmental assessment or reassessment and an inventory of resources and supports. The care plan information must be electronically documented and available 24/7 to any practitioner providing CCM services and other appropriate practitioners and providers.
  • Hospitals must provide the patient a written or electronic copy of the care plan and document the receipt in the electronic medical record using certified information technology.
  • Hospitals must manage care transitions between and among health care providers and settings. This management includes referrals to other clinicians; follow-ups after an emergency department visit; and follow-ups after the patient is discharged from hospitals, skilled nursing facilities, or other health care facilities. To support such care transitions, clinical summaries must be electronically submitted using certified information technology.
  • Hospitals must coordinate with home- and community- based clinical service providers necessary to support the patient’s psychosocial needs and functional deficits. This communication between the hospital and the clinical service providers must be documented in the patient’s medical record.
  • Patients and caregivers must have the opportunity to communicate through the telephone, secure messaging, internet, or other asynchronous remote consultation methods with practitioners, regarding the patient’s care.
  • Hospitals must have certified information technology under the Office of the National Coordinator for Health Information Technology Health Information Technology Program. Technology used for core capabilities for CCM services and scope of service requirements referencing a health or medical record must be acceptable under the Electronic Health Records Incentive Programs of December 31 of the preceding calendar year.

Hospitals using telehealth to develop patient population health and care coordination services should take a serious look at CCM billing under the OPPS, and keep abreast of developments that can drive recurring revenue. Interested providers can also use the proposed rule as an opportunity to join the conversation, as CMS will accept comments until August 1, 2015. The final rule, and response to comments is expected to be issued early November, 2015.


For more information on telemedicine and telehealth, including publications, presentations and other materials, visit Foley’s telemedicine resource center.

Please note Foley Summer Associate, Arrie N. Kustin, was also a contributing author of this post.

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