Staying Compliant with Chronic Care Management

Chronic Care Management (CCM) can be a powerful addition to your practice.  It improves patient outcomes and gives your team more opportunities to stay connected with patients between visits. 

Lately, CCM compliance has been under increased scrutiny.  But, most enforcement actions aren’t related to fraud. Instead, they're due to incomplete documentation and missed requirements.  

It’s no longer enough to simply offer CCM and submit claims. Providers are expected to show that they’re delivering meaningful and ongoing care to patients with chronic conditions.  

That means your CCM program must be built on:

• Accurate documentation
• Proper billing practices
• Clear clinical justification

ThoroughCare centralizes CCM workflows into a single system, allowing care teams to deliver more efficient and consistent care.  In this video, we dive into the key steps for running a successful CCM program.

Patient Eligibility

In order to qualify for CCM a patient must have at least two chronic conditions and be at meaningful risk if those conditions aren’t managed. That risk could be hospitalization, disease progression, or functional decline.

The record needs to clearly explain why. If that reasoning isn’t written down, it doesn’t exist from a compliance standpoint.

Initiating Visit

For new patients, or patients who haven’t been seen in the last year, CCM requires a face-to-face visit before billing can begin. This is where the program is introduced and discussed.  It can take place during a standard E/M visit or an Annual Wellness Visit.  Either way, it must occur and it has to be documented.

It’s a simple requirement that is often missed or overlooked and can invalidate months of billing.

Patient Consent

Patients must explicitly agree to participate in CCM.  Furthermore, your documentation must show that the patient explicitly agreed to CCM and was informed of monthly cost-sharing, that only one provider can bill CCM per month, and that the patient has the right to opt out at any time.

Billing

Considering CCM is billed based on time, your documentation has to do more than show that work happened. It needs to show how much time was spent and what that time included.

That might involve patient outreach, medication reviews, care coordination, or communication between providers.  Every minute needs to connect back to a specific, documented activity.  A good rule to keep in mind is if you can’t trace it, you can’t bill it.

Any clinical staff contributing time must be working under the direction of the billing provider under incident-to guidelines. That relationship should be clear in both workflow and documentation.

Make sure to bill the right codes the right way. Use the correct CPT code based on time and complexity. Differentiate non-complex vs. complex CCM.

Complex CCM requires not just more time, but also documentation that supports moderate or high complexity medical decision-making. The provider’s notes need to clearly reflect that level of complexity.

Lastly, only one provider can bill CCM for a patient in a given month. Overlapping billing can trigger compliance issues.

How to Set Your Program Up For Compliance

Using a leading care management software like ThoroughCare can help bring consistency to your program. With step by step processes and automated workflows, software can help to streamline a CCM program and help with compliance.

It's also essential to develop clear policies and procedures. Staff roles and responsibilities should be clearly outlined, along with workflow and documentation requirements for the program.

Monthly reviews are highly recommended.  Consider conducting mock audits and doing internal quality checks as these can catch small issues before they become bigger problems. Education and training is key to make sure your team stays up to date on all program rules, regulations, and compliance.  

When eligibility is clearly documented, consent is properly captured, time is accurately tracked, and billing is done correctly, your CCM program is in a much stronger position to succeed.

If you need help starting or growing your CCM program, reach out to us.