October 7th, 2021
Categories: Practice Management, Training & Education

Home-based primary care reimbursement

Date: 10|07|2021   Approx. 2 min. read
Author: Brianna Plencner, CPC, CPMA  Senior Consultant & Manager, Practice Development, HCCI

One of the most common billing questions I receive is, “how can I get paid for all of my non-face-to-face time with patients and caregivers?”.  An appropriate solution to this question is offering Chronic Care Management (CCM) services. Yes, while CCM services do have requirements including the use of a Certified Electronic Health Record (CERT), creating and maintaining a comprehensive electronic care plan, and documenting your time spent throughout a calendar month, I argue that it’s well worth the time and effort if you rely mostly on fee-for-service (FFS) reimbursement.

Planning for implementing a CCM program by 2022 will be worthwhile, especially since in the CY 2022 Medicare Physician Fee Schedule Proposed Rule (MPFS), the Centers for Medicare & Medicaid Services (CMS) is proposing to increase the wRVU and payment for CCM services, in addition to creating a new CCM add-on code for when the billing practitioner personally spends the time. Refer to our previous blog post for graphs on the specifics of the changes to the CCM codes.

Even if you have a current CCM program, I recommend reviewing your current protocols and billing as the Office of Inspector General (OIG) did conduct an audit of CCM services in August 2021 that resulted in identifying over 3.3 million in overpayments for CCM services between 2017-2018. Click here to review a summary of OIG’s findings. Your practice may have also received a comparative billing report (CBR) comparing your CCM billing trends to those of your peers and national benchmarks. You would want to pay special attention to compliance controls if you received a CBR identifying outlier trends. Information on the CBR’s for CCM services was referenced in this MLNConnects issue from April 2021.

Common pitfalls I see when reviewing practices CCM programs include:

  • Not capturing all eligible time from clinical staff and qualified healthcare professionals from billable activities
  • Billing for complex CCM only because 60 minutes was spent without supporting complex decision making
  • Failure to create, maintain and provide the patient/caregiver a copy of their CCM comprehensive care plan
  • Lack of specificity or supporting documentation of how CCM time was spent during a calendar month

For additional information on CCM, refer to HCCI’s CCM Care Plan Requirements resource or our Advanced Coding Opportunities resource for complete CPT code details.