What are the documentation requirements to pass a chronic care management audit?
Proper documentation is important for Chronic Care Management (CCM) services to ensure that healthcare professionals can confirm the services they provided and receive appropriate reimbursement. The following are some documentation requirements for CCM services to help prepare you with a medicare audit checklist:
- Patient consent: Providers need to document that they have obtained patient consent (verbal or written) for CCM services in the EHR, such as the scope and nature of the services, the patient confirming they are not receiving these services by another provider, the potential cost the patient may need to pay if they have not reached their deductible at the beginning of the year or the 20% coinsurance cost if they do not have health insurance to cover this cost as well as the patient’s right to revoke consent.
- Comprehensive care plan: Providers need to document that they have developed and shared with the patient a patient centric comprehensive care plan, including goals, medications, allergies, and interventions.
- Care management and coordination: Providers and/ or their clinical staff need to document their efforts to effectively provide care management and coordinate care across multiple providers and settings, such as communication with other providers and tracking referrals.
- Medication management: Providers and/ or their clinical staff need to document their review and management of the patient’s medications, such as documentation of any changes made to the medication therapy and providing the reasons for those changes, as well as the proper medication dosage and frequency the provider has requested the patient to take in case the patient is taking the medication incorrectly.The provider needs to be notified if there are any medication changes or the patient is experiencing an undesirable side effect so the provider can be continuously monitoring for medication interactions which is in the month ccm services are billed the provider needs to have monitored for any medication interactions.
- Allergy Management: Asking the patient if they have any new allergies and notifying the provider of any new updates to the patient’s allergies.
- Transitions of Care: Identifying if the patient has been recently discharged from one of the following settings and returned to their home, domiciliary, rest home or assisted living facility need to have transitional care management services: Inpatient Acute Care Hospital, Inpatient Psychiatric Hospital, Long Term Care Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility, Hospital outpatient observation or partial hospitalization; Partial hospitalization at a Community Mental Health Center
- Systemic assessment: Providers and/ or clinical staff need to document that they have performed a systemic assessment of a patient’s medical, functional and psychosocial needs.
- Monitoring: Providers and/or their clinical staff need to document continuous monitoring of the patient’s health status, such as regular communication with the patient and follow-up
- Time spent: Providers and/or their clinical staff need to document the time spent delivering CCM services, such as recording the start and end times in their EHR, the type of service provided, and the duration of each service. It is important to utilize a chronic care management software that not only bills based on the required time element being met to bill for ccm services but also the required scope of services are met which have been discussed above since many chronic care management platforms are triggered just on time but not the scope of services being met. Otherwise, you will need to have more time spent auditing your CCM team. Keeping detailed and accurate records of patient consent, supporting the required scope of service elements are met, along with the time requirements fulfills the reimbursement criteria to be in compliance with Medicare CCM regulations. CareVitality’s CCM platform makes sure the scope of service as well as the time requirements are met before CCM services are billed so you are able to pass a CCM audit.
How to avoid failing a Medicare Chronic Care Management audit. Follow this Medicare audit checklist.
To avoid failing a Medicare Chronic Care Management (CCM) audit, your practice must adhere to all the requirements for providing CCM services which include fulfilling the full scope of services and the time requirements. Here are some tips for a chronic care management medicare audit checklist to help you avoid potential pitfalls during audits:
- Ensure that your practice fulfills the eligibility criteria for delivering CCM services, such as having a qualified healthcare professional, offering 24/7 healthcare access, and obtaining patient consent and having it documented in the EHR.
- Make sure to have a patient-centric comprehensive care plan to include all the patients chronic conditions whether you are treating them or another provider put in place prior to initiating ccm services.
- Recurring CCM services which are billed for the following months once the patient-centric comprehensive care plan is put in place need to address each of the problems listed in the comprehensive care plan.
- If the patient is diagnosed with a new chronic condition the care plan needs to be revised and updated to include the new chronic condition. You need to have a process in place or a CCM software that notifies you when a new chronic condition has been added to make sure the patient-centered care plan is updated prior to preceding with continuing CCM services. CareVitality’s CCM platform updates you to revise a care plan when a new chronic condition is added in the CCM billable provider’s EHR.
- Record all CCM services provided in the patient’s medical record, including the time it took place (start time and end time), duration and the specific activities performed. The documentation should be comprehensive and unique to each patient and fulfill the documentation requirements discussed earlier in the blog.
- Utilize the appropriate CPT codes when submitting claims for reimbursement. The codes for CCM services include the following:
- CPT Code 99490 (for at least 20 to 39 minutes of non-face-to-face care per month),
- CPT Code 99439 for each additional 20 minute interval billed up 2x along with the initial
- CPT Code 99490 (from 40 to 59 minutes or 60+ minutes of non-face-to-face care per month),
- CPT Code 99487 for 60 to 89 minutes of complex CCM services requiring medical decision making of moderate to high complexity and establishment, implementation, revision or monitoring of a comprehensive care plan.
- CPT Code 99489 is an add-on code to CPT Code 99487 if the time it takes is 90 or more minutes for services qualified to bill for CPT Code 99487.
- Ensure that you use the proper CPT codes and clear documentation of your CCM time spent and documentation requirements being met supports them.
- Monitor the time spent providing CCM services to ensure compliance with the minimum billing requirements. You should provide at least 20 minutes of non-face-to-face care management services per month, which involves fulfilling the required scope of services which may involve care coordination if needed, medication management, and chronic condition monitoring. The time spent should include your start time, end time and total minutes each time during the month.
- Ensure you train your staff on providing CCM services and appropriately bill for them. Staff should know the billing codes used for chronic care management reimbursement and the documentation requirements.
- Stay updated on changes in Medicare reimbursement policies and regulations for CCM services, and make any changes to your documentation and processes to ensure compliance.
By following these tips, you can ensure your practice complies with all the requirements for delivering CCM services and avoid potential audit pitfalls. Be diligent in your documentation and billing practices, and seek guidance from experts or consultants if any aspect of providing CCM services is unclear.
