Can you bill for Chronic Care Management (CCM) program oversight according to the Centers for Medicare and Medicaid Services (CMS)?

Billing for Chronic Care Management Program Oversight Under CMS

Yes, you can bill for program oversight of Chronic Care Management (CCM) services according to CMS guidelines, which specifically allows physicians to be reimbursed for care plan oversight services that include CCM program supervision.

CMS Reimbursement Framework for CCM Oversight

CMS has established specific mechanisms for billing program oversight of Chronic Care Management services:

Eligible Billing Codes

• Medicare recognizes the physician work involved in CCM program oversight through specific billing codes:
  • Care plan oversight service codes (99374-99380) can be used for cumulative physician time spent over a 30-day period 1
  • These codes include telephone time but cover broader oversight activities 1
  • Documentation of complexity or time spent is required for reimbursement 1

Documentation Requirements

• To bill for CCM program oversight, physicians must:
  • Document the encounter and complexity of decision-making 1
  • Submit charges on a CMS-1500 form 1
  • Track time spent on oversight activities if using care plan oversight codes 1

Program Oversight Components

The medical director responsibilities that qualify for billing include:

• Coordination of the initial patient evaluation and goal development 1
• Development of strategies to support long-term goals 1
• Tracking patient progress toward goals 1
• Communication with referring physicians 1
• Program monitoring and quality improvement activities 1

Payment Considerations

When billing for CCM program oversight, be aware of these payment considerations:

• Many private insurers reimburse for telephone management codes at approximately 26% of charges 1
• Medicare plans may pay for telephone calls during which care plans are organized or reviewed 1
• Some Medicaid managed care plans include oversight as covered services under capitation 1
• Collection rates for telephone-based care management in insured populations have been reported at around 33% 1

Common Pitfalls and How to Avoid Them

Potential Challenges

• Inadequate documentation of time spent on oversight activities
• Confusion about which codes to use for different oversight activities
• Lack of clarity on direct vs. indirect supervision requirements

Best Practices

• Maintain detailed documentation of all oversight activities and time spent
• Clearly differentiate between direct patient care and program oversight activities
• Ensure that oversight activities align with CMS definitions of medical necessity
• Use standardized templates to document oversight activities consistently

Recent Trends in CCM Utilization

Despite available reimbursement mechanisms, CCM services remain underutilized:

• Only 3.4% of eligible Medicare beneficiaries received CCM services in 2019 2
• Only 7% of physicians and 1.3% of nurse practitioners/physician assistants billed for CCM services in 2018 3
• Higher utilization is associated with practices serving more beneficiaries and those with higher percentages of dually enrolled patients 3

By properly documenting and billing for CCM program oversight, providers can be appropriately compensated for the significant work involved in managing these complex patients while improving health outcomes through structured chronic care management.