Chronic Care Management : Bringing Value, Quality and Outcomes to the Medical Community

Amina Abubakar, PharmD, AAHIVP

▪ Independent Community Pharmacy in Charlotte, NC

▪ CPESN Luminary Pharmacy Owner

▪ Innovative and Expansive Community Clinical Services

▪ Accredited Diabetes Self-Management Training (DSMT) Program

▪ Point-of-Care Testing program

▪ Diabetic Shoes & Compression

▪ Durable Medical Equipment

▪ Insulin Pump Training

▪ Routine & Travel Health Immunizations (Yellow Fever Certified)

▪ Pharmacogenetic Testing Program with MTM

▪ Chronic Care Management via provider collaboration

The Rx Clinic Pharmacy Team

▪ Ambulatory Care Department via provider collaboration

▪ Pharmacists embedded in the medical practice

▪ Hybrid Community-Ambulatory Care Pharmacists

▪ Management Services Organization

▪ Federally Qualified Health Center (FQHC)

The Rx Clinic Pharmacy Team

Our Educational Endeavor

WHY CCM?

WHY DO WE PARTICIPATE IN CHRONIC CARE MANAGEMENT?

◼ ½ of all adult Americans have chronic conditions

◼ 1 in 4 Americans have 2+ Chronic Conditions

◼ 2/3 of Medicare beneficiaries have 2+ chronic conditions

◼ In 2014 Medicare benefit payments were $597 billion

◼ 99% of Medicare spending is on patients with chronic conditions

CCM is patient centered care requiring more centralized management of patient needsThis allows for better health outcomes

WHAT …..

Overview of CCM

◼ Chronic Care Management (CCM) is a medicare part B service performed by a physician or a non-physician practitioner and their clinical staff staff every month for patients with 2 or more chronic conditions.

◼ Chronic Conditions Defined◼ Expected to last 12 months or until death

◼ Places patient at risk of:

◼ Death

◼ Acute exacerbation/decompensation

◼ Functional decline ◼ Comprehensive care plan established, implemented, revised, or

monitored

PATIENT ELIGIBILITY:

◼ Medicare beneficiary

◼ 2 Chronic Conditions

◼ Patient does not have same day visit as CCM

◼ Patient is not in a Home Health System

◼ Must have had an evaluation by the provider before billing for CCM

CCM Services Include 5 Core Activities

1. Recording structured data in the patient’s health record2. Maintaining a comprehensive care plan for each patient3. Providing 24/7 access to care4. Comprehensive care management5. Transitional care management

The Care Team

Qualified Health Professionals (QHP)

● Physicians (see exception)● Physician Assistant● Nurse Practitioner● Clinical Nurse Specialist● Certified Nurse Midwife

Clinical Staff◼ Any practitioner that can be

billed incident-to◼ Personnel that works under the

supervision of the QHP◼ Advanced practice registered

nurses, registered nurses, licensed specialist clinical social workers, licensed practical nurses, pharmacists, certified medical assistants

Non-clinical Staff◼ Any personnel who are not clinical staff

or QHPs◼ Time cannot be counted toward the

CCM time requirement◼ Can facilitate the service delivery to

maximize the pharmacist’s time with the patient

◼ e.g. receptionist, pharmacy support staff that books appointments, relays CCM service information (Per APhA example)

CMS uses the term “auxiliary personnel” instead of clinical staff

Clinical Staff◼ Terminology used by CPT◼ Licensed practitioner who can assist in the

delivery of services, in this case CCM, under the general supervision by a QHP

Auxiliary Personnel◼ Terminology used by CMS◼ Individuals working under physician or other

QHP supervision in an incident arrangement and whose services are billed by the QHP

Practitioner Eligibility: Who can bill for CCM ?

◼ Only QHPs may bill CCM services and preferably the primary QHP

◼ Only one QHP may bill per calendar month◼ Services provided directly by the appropriate

practitioner OR by clinical staff incident-to count toward the minimum amount of time required to bill the CCM

◼ General Supervision - exception to Medicare’s “incident-to” rules applied for clinical staff

Non-clinical staff time cannot be countedNot within the Scope of Practice of limited license

physicians and practitioners such as:◼ Psychologists◼ Podiatrists◼ Dentists

However, referral or consultation with such practitioners by the billing practitioners may be required to coordinate and manage care

Types of Practitioner Supervision

Direct Supervision - physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Does NOT mean the physician must be present in the room.

General Supervision - procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required

◼ Incident-to regulations require direct supervision◼ See free module on Incident-to Regulations for

more information◼ CCM is exempt from this regulation and can be

provided under general supervision

CCM BILLING CODES

HOW…..

CCM delivered through Collaborative Relationship

What are the key points for collaboration with providers?

● As it stands right now, providers do not have time to provide this service○ Nurses and other staff are busy with lab results, triaging, making referrals

● Pharmacists have the knowledge of medications and disease states○ monitoring, lifestyle changes, treatment guidelines

● Collaboration is a WIN-WIN

Fee-for-service Quality of Care

Inside the medical practice

● No time○ Refill requests from so many pharmacies○ Prior authorizations○ MTM recommendations pile up○ Patients overbooked○ Quality measures overlooked

● Third party rejections for inappropriate note documentation● New Pt visit ~30 minutes and Follow up visit ~15 minutes

○ Just enough time to address 1 problem. The main problem!● Front desk

○ In addition to check in, check out they answer non stop phone calls from pharmacies, patients checking on the status of refills, PA, cancel or change appointments, fax and receive medical records

In Other Words….

It is a MAD HOUSE!!

These pressure points are our opportunities

Implementation

Chronic Care Management (CCM): Settings

Requirements & Considerations with Initial Implementation● Create an arrangement with a Supervising Medical Provider

○ Best Practice to set up a Clinical/Collaborative Practice Agreement with supervising medical provider

○ General Supervision● Documented verbal confirmation from the patient is required (i.e. EHR documentation)● Be transparent regarding Copay/Deductibles

○ Consider starting service in the year after deductible has been met○ Consider starting service with dual eligible patients with secondary insurance coverage○ Copay ~$8.00 / Deductible not met ~$42

● Strategize how to capture time spent from all qualified medical staff involved in patient’s care● Be an expert on EHR capabilities

○ Templates○ Communication tracking○ Time tracking

Practical Implementation

● Identify Collaborative Partner○ Run a report of Medicare patients that are eligible for CCM ○ Approach the providers with majority mutual patients○ Explain to the provider your med sync program and how it can benefit them if you did their CCM○ Share your value ○ Obtain contract

● Discuss needs for Implementation○ Obtain access to their EHR to document

■ Share the pros vs. cons with and without EHR access○ If you do not get permission for EHR access, use an online platform such as DocsInk

● Train your staff on the CCM program○ Roles of different staff members○ What interactions count? Where and how to document?○ Time capture

Practical Implementation

● Implementation of CCM program○ Verbal enrollment○ Create initial care plan and have provider approve and sign off

■ Note: if performed with AWV or E&M visit, then you can bill for the initiation of CCM■ Development of Care Plan is contracted time

○ First CCM encounter with patient■ Review full Care Plan if possible■ At least counsel on highest priority items based on medical necessity to reduce morbidity and mortality

○ Document the encounter and time stamp each topic discussed● Tracking of progress throughout the month

○ Continue working on open cases for patients until proper amount of contracted time for the month is reached○ Work with providers and nursing staff to identify and document on patients that may be complex CCM cases

● Billing at the end of the month○ Complete the encounter note○ Send notes and billing charges (if applicable)○ Invoice the provider

Resources for Data and Time Capturing

Using the provider’s EHR

◼ Efficiency and capabilities differ among EHRs◼ Templates can be created in most systems◼ Patient cases or tasks can be used to capture the

activity and time spent amongst different users◼ Use billing codes to run reports on productivity◼ Challenges

◼ Identifying the incomplete CCM encounters that need to be completed before the end of the month

◼ Developing the systems

Using an outside platform

◼ Many companies to choose from for Care Plans or CCM documentation and tracking

◼ May be used as a stand-alone platform or in conjunction with EHR

◼ HIPAA Compliant Information Exchange for encounter notes and billing

◼ Challenge to get providers or nursing staff to use an outside platform

COMMUNITY PHARMACY

◼ Incorporated into workflow◼ Medication Synchronization program◼ Use of technicians◼ Coordination of care from MTM◼ Document all activity in provider’s EHR◼ Provider bills for CCM◼ Pharmacy is paid per contract agreement

INSIDE A MEDICAL PRACTICE

◼ Pharmacists embedded in the Clinic◼ Pharmacists captures all activities from medical staff and documents in EHR◼ Provider bills for CCM◼ Pharmacists reimbursed based on contract agreement

LONG TERM CARE

◼ Assisted Living or Skilled nursing for patients with part B coverage◼ Many patients are seen for episodic care and chronic care likely to be secondary◼ Pharmacist can follow patients labs and outcomes◼ Provider bills for CCM◼ Pharmacists reimbursed based on contract agreement

FQHC / Rural Health

Effective January 1, 2018, RHCs and FQHCs are to bill CCM using a General Care Management code (G0511) instead of the CPT code 99490

◼ - At least 20 minutes of clinical staff time directed by a physician or other qualified healthcare provider, per calendar month

◼ This can be CCM or BHI (Behavioral Health Integration)

◼ BHI is a care coordination code for patients with behavioral health disorders (see attached document for more information)

◼ - Must meet all requirements that the standard CCM code (CPT 99490) must meet

◼ - RHC and FQHC face-to-face requirements are waived for the purposes of CCM

◼ - 2018 CMS Payment PMPM: $62.28 (based on the average of 3 national non-facility PFS payment rates)

◼ G0511 may not be billed by the QHP during the same month as other care management services are billed, which are the TCM, home healthcare or hospice care

supervision, or certain ESRD codes

Chronic Care Management Online Platforms

Pros

◼ Tracks time spent for complex and non-complex actions

◼ Alerts and prioritizes patients that can be completed before the end of the month

◼ HIPAA compliant communication between providers and medical staff

◼ Tracks CCM services for billing and quality assurance

Cons

◼ Definition of “integrated with EHR” doesn’t mean that it will update the EHR◼ Note may appear as a PDF which will have to be

scanned◼ Staff may still need to up the EHR based on

information in the PDF documentation◼ Billing CCM based on a PDF or document

without updating or meeting measures within the EHR will NOT always count towards meeting quality measure.

Costs and Business Planning

◼ Costs to consider◼ Pharmacist time for completion and documentation◼ Additional software programs for tracking or documentation

◼ Potential Revenue◼ How many eligible patients does the practice(s) have?

◼ How many active Medicare patients?◼ How many active Medicare patients with supplemental insurance?◼ Out of both of those sets patients, how many have 2 or more chronic conditions?

◼ Conservatively calculate total potential monthly/yearly revenue using non-complex CCM reimbursement◼ Clinical Pharmacist Allocation

◼ Using the potential revenue generated based on the information above you can determine how many days per week you can allocate to this clinic for CCM

EXAMPLE OF CCM WORKFLOW l

CCM WORKFLOW IN RX CLINIC PHARMACY

Clinical Pharmacist for face to face consults and interventions Ex: PGx, POCT, Immunizations, DSMT, Medical Equipment Training

Prescription verification: Yields most Drug Therapy Problem opportunities but limited time for interventions

Enhanced Services Care Team: Communicate with Prescribers, Care Managers and Patients to coordinate care

THINGS TO CONSIDER DURING CCM

Patient

Housing Security

Poverty

Health Literacy

Food Security

Domestic Violence

Culture

• Current VaccinesVaccines

• Vitals: Ht., Wt., BMI, BP, Pulse• MeasurementsVitals

• Lab Results• Including but not limited to Lipid Panel,

CBC w/diff, Comprehensive metabolic panel, Urine Culture

Results

• Includes but is not limited to New Patient Visits, Follow up / Chronic / NonAcute, Chronic Care management, Annual Wellness visits, etc.Visits

• Family History• Social History• Surgical History• Gyn/OB history• Past Pregnancies• PMH

History

• Preventative services that are past due for that patient• Examples: Annual Wellness Visit, Vaccines that are due, Depression

Screening, Fall Risk ScreeningQuality

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