01-038 Facility CCM Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of a sample of claims for Medicare Facility Chronic Care Management (CCM) services billed on dates of service from January 1, 2019 through December 31, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers may wish to consult when submitting claims.

Background

In November of 2019, the Office of Inspector General (OIG), published a report titled “Medicare Made Hundreds of Thousands of Dollars in Overpayments for Chronic Care Management Services” (A-07-17-05101). The OIG noted that CCM services are a relatively new category of Medicare-covered services and have multiple restrictions on when and how they can be billed. In its report, the OIG looked at both physician and facility claims for CCM services. The CMS defines CCM as a physician-provided or physician-directed service; therefore, CMS will pay the outpatient facility for CCM services only when the facility provides these services at the direction of a physician. There is no requirement that CCM services billed by outpatient facility have a corresponding claim billed by a physician; however, because CCM is a physician-directed service, it is reasonable to expect that in most cases a physician would submit a claim for the same service. The OIG reviewed CCM services billed by facilities without a corresponding physician claim and identified approximately $1,162,562 in potential overpayments. CMS tasked the SMRC to review a sample of outpatient facility claims to determine if claims were billed properly.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review on CCM facility claims. Noridian will complete medical review on a sample of claims related to CCM services. The SMRC will conduct reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

TOB CPT
  • 13x: Outpatient Hospital
  • 99487: Complex chronic care 60 minutes
  • 99489: Complex chronic care additional 30 minutes
  • 99490: Chronic care management service 20 minutes
  • 99491: Chronic care management service 30 minutes

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Medical record documentation to support beneficiary having two or more chronic conditions (expected to last at least 12 months) with significant risk of death, functional decline, exacerbation, or decompensation
  2. Annual Wellness Visit (AWV), Initial Preventive Physical Exam (IPPE) or comprehensive Evaluation and Management (E/M) performed prior to billing CCM services for a beneficiary new to Chronic Care Management (CCM) or for beneficiaries not seen by the billing provider within the last 12 months
  3. Practitioner, nurse, and ancillary progress notes
  4. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  5. Verbal consent or a written consent signed by beneficiary or caregiver and must include the following:
    1. Description of the CCM services
    2. Ability to Revoke/Right to stop CCM services
    3. Responsibility for cost sharing
    4. If verbal consent obtained for Chronic Care Management (CCM), documentation to support narrative discussion and prior permission acceptance
  6. Comprehensive care plan with measurable goals was established, implemented, revised, or significantly monitored
  7. Comprehensive care plan was provided to the beneficiary and/or caregiver
  8. Medical record documentation to support time spent on Chronic Care Management (CCM) services for the CPT level of code billed
  9. Medical record documentation to support the dates of service billed on the claim
  10. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
    1. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed and dated by the physician
  11. Advance Beneficiary Notice
  12. Any other supporting documentation
  13. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits.
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
  • Social Security Act (SSA) Title XVIII, Section 1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
  • Social Security Act (SSA) Title XVIII, Section 1893 (f)(7)(A)(B)(i-iv). Medicare Integrity Program.
  • 42 Code of Federal Regulations (CFR) 410.26(b)(5). Services and supplies incident to a physician’s professional services: Conditions.
  • 42 Code of Federal Regulations (CFR) 425.400(c)(1)(iv)(A)(5).
  • 42 Code of Federal Regulations (CFR) 424.5(a)(6). Basic Conditions.
  • Federal Register. Volume 78. Number 237. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014; Final Rule. Section K. Pages 74414- 74427. https://www.govinfo.gov/content/pkg/FR-2013-12-10/pdf/2013-28696.pdf.
  • Federal Register. Volume 79. Number 219. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015; Final Rule. Section H. Pages 67715- 67730. https://www.govinfo.gov/content/pkg/FR-2014-11-13/pdf/2014-26183.pdf.
  • Federal Register. Volume 80. Number 54. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015; Corrections. Page 14853. https://www.govinfo.gov/content/pkg/FR-2015-03-20/pdf/2015-06427.pdf.
  • Federal Register. Volume 81. Number 220. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Final Rule. Section 4. Pages 80243- 80251 and 80257. https://www.govinfo.gov/content/pkg/FR-2016-11-15/pdf/2016-26668.pdf.
  • Federal Register. Volume 83. Number 226. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Final Rule. Section 60. Page 59577. https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf.
  • The Centers for Medicare and Medicaid Services (CMS). Frequently Asked Questions about Physician Billing for Chronic Care Management Services. January 1, 2019. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/payment_for_ccm_services_faq2019_updateclean012819.pdf
  • The Centers for Medicare and Medicaid Services (CMS). Frequently Asked Questions about Billing Medicare for Chronic Care Management Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/Payment-Chronic-Care-Management-Services-FAQs.pdf
  • The Centers for Medicare and Medicaid Services (CMS). Medical Learning Network (MLN) ICN MLN909188 July 2019. Chronic Care Management Services.
  • Office of Inspector General, A-07-17-05101. Medicare Overpayments for Chronic Care Management Services.

Last Updated Jun 14, 2021