Medicare Care Management Billing Strategies

Featured Speakers

	Craig Holden, PhD, MPH, MBA, Senior Research Scientist with the NORC Walsh Center for Rural Health Analysis
	Susan Rohde, RHIT, CCS-P, CPC, Director, Eide Bailly
	Joy Krush, RHIT, CCS, CCS-P, CDIP, CRHCP, Senior Manager, Eide Bailly

This webinar will discuss new Medicare care management billing codes that can support care coordination and help your organization improve quality of care for Medicare beneficiaries. The presenters will discuss actionable steps to help your organization plan for and implement these billing codes.

From This Webinar

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Transcript

Kristine Sande: Welcome to today's webinar. I'm Kristine Sande, program director for the Rural Health Information Hub, and we're glad that you're joining us today for our webinar, Medicare Management Billing Strategies. So this webinar is the result of a project that we've been working on with our partners from the NORC Walsh Center for Rural Health Analysis as well as Eide Bailly. So, it is my pleasure to introduce those partners as our speakers for today's webinar.

Our first speaker will be Craig Holden, a senior research scientist with the NORC Walsh Center. Craig is a mixed methods health services researcher focused on evaluating the impact of the healthcare delivery system, programs and policy on population health outcomes. Craig leads projects investigating hierarchical condition, category coding, health professional shortage areas, and rural hospital bypass. In addition, Craig leads the evaluation of the Delta Region Community Health Systems Development Program, a health resources and services administration, federal office of rural health policy program aimed at strengthening local health systems.

Next, we'll hear from Susan Rohde, a director with Eide Bailly. Susan has more than 28 years of experience in the healthcare industry with an emphasis on coding, health information management, charge capture, medical necessity, quality of earnings, and documentation. She specializes in reviewing documentation for accurate reimbursement within evaluation and management and all surgical specialties for both ICD-10-CM and CPT codes.

Joy Krush is a senior manager with Eide Bailly. Joy has over 30 years of experience in the healthcare industry with an emphasis in coding, health information management, compliance, charge capture, and documentation improvement. She is trained in ICD-10, CPT, and clinical documentation integrity with understanding of Medicare severity diagnosis related groups and ambulatory payment classification payment methodologies. Joy's work background provides her with the understanding of multiple payment methodologies including cost-based for rural facilities, provider-based, and fee schedules for clinics, and various prospective payment systems. Her work includes reviewing clinic, and facility charge masters, and assisting clients with the implementation of new service reporting such as care management services.

So welcome to our speakers and with that I'm going to turn it over to Craig.

Craig Holden: Thank you. Good morning or afternoon depending on where you're at. Thank you for joining today's session. I'm Craig Holden, researcher with the NORC Walsh Center for Rural Health Analysis. And what we are talking about today stems from work we did the past several months in conjunction with our RHIhub and Eide Bailly, where we worked with a cohort of federal officer rural health policy awardees to hear about their experiences and provide them with technical assistance around preparing for value-based care programs. Today we'll walk through some recent changes CMS has introduced in support of this care, particularly in rural settings.

CMS is continuing its push towards value-based care. By 2030, CMS intends for all Medicare fee-for-service beneficiaries to be in a care relationship where providers are held accountable for both quality and total cost of care. For rural providers, this shift presents opportunities to be paid for services that have long gone unreimbursed. Things like patient navigation, social risk screening, and community engagement. Care management services are a cornerstone in this transition. They're designed to reward providers who prevent hospitalizations, increased use of preventive care, and address social and environmental drivers of health.

So CMS has been expanding the menu of billable care management services over recent years. This includes chronic care management, behavioral health integration, and principal care management. New for calendar years, 2024 and 2025, are several additions that more explicitly support whole-person care, including services to address social drivers of health, caregiver support, and coordination with community-based services.

So, let's take a little closer look at the specific new areas that CMS has added codes to the physician fee schedule. In 2024 social determinants of health risk assessment allows providers to bill for time spent screening patients for social risks using standardized tools, caregiver training services codes, reimburse providers for time spent training a patient's unpaid caregiver, and essential service in some rural areas with workforce shortages. Codes for community health integration services recognize the work of community health workers and others providing care coordination, navigation, and support services. Principal and illness navigation services codes support navigation services for individuals with high risk conditions or complex needs.

And in calendar year 2025, advanced primary care management codes build on chronic care management and principal care management and provide more flexibility and enhance payments for comprehensive team-based primary care. And rural health clinics and federally qualified health centers, for these CMS has made changes that will allow RFCs and FQHCs to bill using individual CPT or HCPCS codes instead of just GO511. This is a shift toward greater granularity and payment transparency. So we'll see this again later, but these new billing codes are administrative updates and a shift in how Medicare supports providers in delivering team-based, patient-centered care that both medical and social needs.

So, if you are interested or need to dive deeper into care management services or these new billing opportunities, you can check out RHIhub's care management page, screenshot shown here. It's a really good resource of information with fact sheets, code guides, and examples of implementation in rural settings. And now I'll turn it over to Susan and Joy to really dig in and provide some more detail.

Susan Rohde: Thank you so much Craig and Kristine for that wonderful introduction. I'm going to share my screen now, so you should be able to see the presentation. All right, happy Friday everyone. Thank you so much for taking time out of your morning or your afternoon, depending on where you are, to listen to this webinar. Sounds like we have quite the nice mix of FQHCs, RHCs, IHS, and some community-based centers as well, so that's awesome.

Today for the agenda, we're going to of course talk a little bit about care management services and why they are so important, give you sort of an action plan for your facility in regards to implementation, talk about some of those core competence of the specific care management services, and then talk about best practices for actually implementing these care management codes.

All right, first topic on the agenda is understanding the care management, and Craig did a really nice job of talking about some of these and you could see in that prior slide on the RHIhub website where these are going to be located. But we really do want to kind of dive into the codes that are applicable for your RHCs, your CAHs, your FQHCs.

Really one of the key staples when we talk about care management is probably what started it all and that's the Chronic Care Management. Just a brief definition of each of these. This is what you will assign if you have those patients that have two or more chronic conditions that are expected to last at least 12 months or until the expiration of the patient. And these conditions are going to be placing the patient at significant risk of death or functional decline. Within that, we also break that out into complex care management, which we will talk about in some of the upcoming slides.

Principal Care Management, that's basically the same as care management except these are for your patients who only have one complex chronic condition and this condition does need to require frequent monitoring and adjustment.

We have Transitional Care Management and this is really to help those patients transition from one healthcare setting to another. So think of the patient that's discharged from the hospital and our goal is to get them back in their home setting. This is really all about continuity of care, reducing the risk of readmission, and just really supporting this patient in that vulnerable time from discharge until they are reacclimating back at their home setting.

We have Behavioral Health Integration or BHI and this is going to be targeted at those patients that have been diagnosed with a behavioral or a mental health condition and really kind of support them in integrating with their primary care.

And then the Collaborative Care Model, or sometimes you might see this as the CoCM. This is integrating that behavioral healthcare model that's truly combining primary care for their medical conditions and behavioral health services all within the same setting.

And like Craig said, we have some new codes for 2025 and one of them is this Advanced Primary Care Management denoted here in red. And this is really focused on value-based care. This is supporting those primary care providers in delivering ongoing patient centered care.

We also have the old classics, the standby, the IPPE, or maybe at your facility, you call this the Welcome to Medicare visit. This is the benefit that patients get within their first 12 months of becoming eligible for Medicare. In their second year of eligibility for Medicare, they can get their Annual Wellness Visit or their initial AWV and then every year after that they are eligible for their subsequent annual wellness visit. The IPPE and the Annual Wellness Visit, these are truly no touch visits. These are really to get patients in the door and develop a treatment or a care plan for them moving forward to stay on the right track and stay healthy.

Then we have the Remote Monitoring services. We have the RPM and the RTM. And this is really Medicare kind of utilizing those technologies to collect and monitor patient's health data outside of traditional clinic settings. This really is going to support some of those that management of their chronic conditions or their acute conditions as well.

Community health integration services, these are services — this is really important — these can provided by clinical staff and these are going to touch on those social drivers of health such as housing needs, nutrition needs, transportation needs, really those SDOHs that are impacting the patient's overall healthcare and their outcomes. This is where we see facilities utilizing those community health workers or those CHWs, and I apologize, there's so many abbreviations and acronyms, so hopefully we do a good job of laying them all out.

And then we have the principal illness navigation services or the PIN services. The PIN services with peer support is that PIN-PS. And these are services that are going to help those patients you have that really have high-risk chronic conditions by helping them navigate and get support through peer support specialists. Typically, the peer support specialists are people who have gone through this themselves, so they are keenly aware of how to work through the system, how to navigate through that.

And, of course, with anything with the government, we definitely could have more of these services to come. That's to be determined. And really maybe you're thinking why would I want to do these care management programs at my facility?

Medicare truly is trying to recognize that these management services do take provider time and effort, so they did establish separate payment for these particular codes because they understand these are taking additional time and resources, spending between appointment times and we also want to be able to help those patients that not only have Medicare but also are dual eligible, so they have the Medicare and the Medicaid to stay on track with their treatment plans because at the end of the day, the goal is to provide the best service and have the best health outcomes for these patients.

We know right now that chronic care management or CCM, it's getting a little bit of extra attention from our MACs, from our Medicare Administrative Contractors as part of some of their review processes. They're closely reviewing these for potential misuse or abuse because we don't want to have any fraud or abuse. But these programs have been clinically proven to reduce hospital readmissions, to reduce emergency department stays because we're helping patients stay on track being healthy.

In a recent survey, and I truly just got these results this morning, so I quickly had to try to incorporate them in here. The chronic care management programs had nearly 5% fewer hospital stays and 2.5% less visits to the emergency room. And if you add that up over time, that can be pretty substantial.

CMS also reported that facilities that are utilizing chronic care management saw a 20% to 30% drop in readmission rates for patients that have these chronic conditions and that improvement is directly linked to the increased use of care management programs. If patients will follow their treatment plans, that is going to lead to improved condition management through medications, maybe healthy lifestyle changes. In turn, that's going to lead to fewer complications and just basic overall better health. Patients are going to get regular check-ins, personalized care plans, and just that really ongoing support that they need, especially if you see the last bullet here.

These are really tools to help reduce geographic, racial, or ethnic healthcare disparities. I'm from North Dakota, so I truly do understand the rural landscape and these are definitely services aimed to help people living in maybe some of those smaller areas that don't have access to the larger urban care.

What are some opportunities when we talk about the Care Management Services? Despite all their efforts, CMS truly hasn't seen the uptick in the utilization of these services that they want to. They're still seeing mainly those traditional office/outpatient (O/O) codes, those E/M clinic codes being assigned as opposed to these care management codes.

Again, there's just so many indirect benefits of the care management codes that can improve your patient's health and wellbeing. Again, CMS isn't seeing the uptick in these codes that they want and that's why they are really pushing and adding new codes every single year. There was one study done retrospectively trying to show a cost-effective analysis for patients who were receiving patient navigator services for colorectal cancer screening. And what they determined was that the ones that received those patient navigator services had a significantly higher rate of completing their screening up to 79% and a significantly lower rate of skipped or canceled appointments as opposed to those who did not.

So truly, again, for every dollar that facilities have been investing in these services, they've seen a return on that investment of about $2.30, mostly by shifting inpatient and urgent care to primary care and then focusing on care management services.

This is just a grid from the American Medical Association, sorry to throw another acronym at you or the AMA. And on the left-hand side you'll see there the actual CPT code because we know now that starting July 1^st, RHCs are going to assign the actual CPT code for the care management as opposed to the GO511. There's the description, the previous utilization, the upcoming utilization, the ratio, the RVU, all of that good stuff.

So again, CMS has not seen the utilization that they want and they are going to keep pushing these care management codes and coming up with new subsets as they see fit.

Now let's talk a little bit about what the action plan can be at your facility. First thing you have to do, identify those eligible patients. We know each of these care management codes talk about a certain subset, so we are going to need to identify within our facility who is eligible for these services and you're going to utilize your electronic health record or your EHR to determine this. Who has chronic conditions? Can you run a report based on ICD-10 codes for XYZ condition? Maybe diabetes, hypertension, CHF. Who has been recently discharged from the hospital or had a recent hospitalization? So maybe we can capture that transitional care management with those patients. Maybe you could run a report on who has the highest ED or hospital utilization rate, so we could capture them with CCM, PCM, that principal care management, the TCM, or the brand new advanced primary care management. And then maybe we can run a report based on behavioral health or mental health ICD-10 codes to capture that behavioral health integration or that collaborative care management model. This should be easy to access within your EMR to run these reports based off those ICD-10 diagnosis codes.

Then we're going to have to have staffing and we're going to want to designate that specific staff to lead care management efforts. Joy and I understand because we work with a lot of RHCs, CAHs, FQHCs, smaller facilities, and we understand that you're either understaffed or your staff is being pulled in all sorts of direction. So you may be thinking, "This is another thing to take on." So, we are truly going to have to get the right staff in the right role.

Who can we utilize for this? RNs or LPN care managers, they already have that clinical background so they can help with that coordination and maybe that medication management. Social workers, social workers are great for the BHI and to help those patients that are addressing those social drivers of health. You could have medical assistants or health coaches. We see health coaches utilize a lot in chronic care management. They can provide that non-clinical follow up lifestyle education. They can provide those reminders to patients.

And then community health workers, this is where we're seeing the biggest boom as far as utilizing community health workers or CHWs. They can truly link patients to within your specific community resources that can help them achieve their healthy lifestyle. We have seen quite the uptick also in facilities utilizing their paramedics or their EMTs in their downtime. If they're not out on a run, they can help assist with some of that patient management and they also have some of that clinical background. Their titles, you may also know them as a case manager, a care coordinator, a patient navigator, maybe an outreach specialist, a community resource specialist, a community health representative, an advocate, an educator, maybe a translation interpretation specialist.

What you're going to want to do at your facility when we're talking about these care management roles is assign tasks to them. So we're going to have policies and procedures really outlining what the duties are that are going to be provided by your clinical or auxiliary staff. Of course, we're always going to want to provide that ongoing education and let them know what their expectations are in their role. We're going to want to give them guidance and requirements for change because we know that these services are often changing or we're adding new ones.

Depending on what the individuals are assigned, that's really going to dictate their supervision requirements are. If it's a billable service, what provider are they going to work under, the supervision of what provider, and any examples of services staff will provide our non-face-to-face phone calls, maybe some of that digital contact, and this is where you really do have to work within your setting and what your patient population is. And if they are... Are they technologically savvy? Can you provide digital contact via email? Will they respond? Are they able to go into the patient portal? Can you put information in there and expect that the patients are getting them out? Or do we have to revert back to some of the older methods such as snail mail and the good old phone call of course?

Billing time for your clinical or your auxiliary staff. And again, these are going to be different in different settings, the RHC, the FQHC, the community-based. But for any services that we are presenting on, there's always a component to them that can be performed by the clinical or auxiliary staff. And again, depending on your setting will depend on if we need the physician supervision, et cetera or that face-to-face. Again, some of these can be furnished under the direction of a billing practitioner or provider as incident two, and then the clinical staff, employees, or contracted services for that particular facility that you're working with.

So, for example, if we're talking about chronic care management or CCM services, they are subject to general supervision rules under the Medicare Physician Fee Schedule or the MPFS. So under their overall direction and controlled as outlined in the comprehensive care plan, that care plan does need to be drawn up by a provider, but the billing practitioner does not need to be physically present when all of the services are furnished. So your auxiliary staff can definitely be making phone calls, having discussions with patients, et cetera, underneath the general supervision blanket.

When we're talking specifically about care management type services, there is an expectation to some of the direct supervision rules for these and direct supervision is the provider within the facility. So, for example, chronic care management services are subject to general supervision rules and some care management are under direct supervision, so we do always want to make sure we're keeping up with that as well.

When we talk next, what you're going to do as far as implementation. We really do need to internally have some policies and some workflows and as structured as we can make them, the better. That's really going to help guide your care management program and really hone in on that standardization and that compliance. That way if any of your staff happen to leave, someone else can slide into that position.

Key workflow components, again, very important to identify the patients that are eligible. Just think about the IPPE. You have to be within your first 12 months of Medicare, so somebody is going to have to be checking that the patient is eligible. Maybe that patient received their IPPE somewhere else a month ago, they can't also receive that at your facility. So again, it's going to boil down to making sure that the patient is eligible.

Every single one of these care services requires consent documentation, either verbal or written. So consent is going to be a very big part of your policy and workflow. They also all require care plan development and documentation standards. And the documentation standards are different for each code, so we are going to want to look at those individually. A majority of these codes are based on time, so we are going to have to document our time and be able to track it for the billable portions of these management services.

And then just coming up with a monthly task checklist for the care managers. I don't know about a lot of you, but I like to see a checklist in front of me and then be able to cross off what I've done. And we believe that works best with care management services as well.

We constructed kind of a checklist like we were just talking about. This one is for chronic care management, but you could easily replace chronic care management with whatever care management service you're doing. So maybe you're doing principal care management, transitional care management. You would just sub out chronic care and put in which service you are doing. But we really do think that this is an excellent checklist if you are just getting started in care management services,

We have the criteria on the left. So for instance, staffing. Has your facility determined the staffing model that you're going to use? And does the provider understand their role in the service offering? Yes, no, not applicable, and then any comments. Maybe in the comments is where you are going to put the staff that's responsible for this particular bullet point.

Implementation considerations. Is your chronic care management documentation going to be incorporated into the medical record? And is there a process at your facility to exchange this documentation with all the providers that need to be able to see it? Yes, no, not applicable. And then again, maybe who's responsible for this task or maybe if you know there's an issue, that's where you put the comment. This has just continued on. And then finally the last one.

Next, we're going to talk a little bit about the core components of each specific care management codes. We'll talk about chronic care management and complex care management first. Again, these are the patients who have two or more chronic conditions that are expected to last at least 12 months. This is pretty subjective and a gray area. So, this is left up to your provider to determine if the patient's hypertension is considered chronic, is it going to last at least 12 months, or until the death of the patient? Chronic conditions could be anything that's putting the patient at risk for exacerbation, decompensation, or just a basic overall functional decline that's moving towards death.

Who can provide these services and under which these services can be provided? The MD or the DO, certified nurse midwives, clinical nurse specialists, nurse practitioners and then our physician assistants or our PAs.

Complex care management is similar to chronic care management. The only difference is the amount of time because remember, a majority of these codes are timed based. The difference here is going to be the amount of time that is spent with the patient.

CPT code 99490 for chronic care management is at least 20 minutes. Then we have an add-on code of 99439 for each additional 20 minutes. And these are per calendar month. CMS does not say there's a specific date you have to assign these on. You can cater it to your facility to assign these codes when you meet the time requirement. Or maybe you're going to assign these codes every 30th of the month, however you choose to do it, as long as your documentation supports it. This add-on code of each additional 20 minutes does have a Medicare Medically Unlikely Edit of 2. So, assigning more than 2, you more than likely will not get paid for.

Again, they have done multiple two or more chronic conditions expected to last at least 12 months. And you do have to have a documented care plan that has been established, it's implemented, it's revised, and it's being monitored.

As far as complex, same thing goes except you have to spend at least 60 minutes to assign code 99487. And the add-on code for each additional 30 minutes is 99489. This has a Medicare Medically Unlikely Edit for the number 4 for part A, and up to 10 for part B. So again, that's an add-on code for each 30 minutes. I have myself never seen it used more than two times because that's just a lot of time spent. So, in addition to the chronic care management requirements, this documentation has to show that the patient's condition requires moderate or high medical complexity, medical decision making as defined by the evaluation and management guidelines.

Then we will talk about principal care management. The documentation standards here, this is really going to cover specific services to help manage care for a single high-risk condition that puts the patient at risk of hospitalization, acute exacerbation, physical or cognitive decline, or potentially death. Patients who have one chronic high-risk condition that's expected to last at least three months.

Typically, when we see this, it's a condition such as cancer. And the codes here are 99424 for the first 30 minutes and then 99425 for each additional 30 minutes with the Medicare Medically Unlikely Edit being 2 here. What's important to note for this PCM is it requires the development, the monitoring, and the revision of a specific care plan focusing on that condition or that disease. Typically, CMS is going to be looking for adjustments in the medication or the management that's unusually complex due to other comorbidities the patient may have. And it's really going to require that ongoing communication and care coordination between all the providers that are working with this particular patient.

And with that, I am going to turn it over to my colleague, Joy, to finish out this presentation.

Joy Krush: Thanks Susan. So, with the next one, we're going to talk about is Transitional Care Management. And this one, if you think about if you are associated with a hospital in particular in the hospital setting, we have a lot of metrics. We have to meet, readmission metrics, return visits to the ED, that type of thing. So when TCM came out, this is I thought, really a good care management that not only helps the patient but kind of helps hospitals manage those situations of readmissions in returns to ED because this is when again, a patient has been, they've been in care from an inpatient hospital, partial hospitalization, observation status, or even in a SNF, and we're getting them back into the community setting.

And so it's that follow-up contact with the patient and then we have the follow-up visit. But so often what would happen in the past, we'd have their return office visit scheduled, but there was nothing in between. So let's just take that congestive heart failure patient who was on IV Lasix in the hospital, now they're on their scheduled home dosage amount. But if we have TCM involved, we might be calling that patient, asking them what their weight is, learning quickly on that we don't have the right dose for that patient. And if we don't get that established more quickly, likely they could end up back at the hospital, in the ED, or even back into the inpatient setting. So, this really is I would say a very good opportunity both from a hospital setting and then from the clinic setting.

And these are the codes. Now, the unique things with these codes are whether it's going to be the follow-up visit's going to be within 14 days or within seven days. And this kind of goes back to the complexity, you think about your MDM grid, the complexity of the patient, how quickly is our follow-up going to be? And again, the required elements is we do have to have communication with that patient within two business days of discharge. So that's going to be the key thing that has to be done within two business days.

And then again, based on what code we're going to report is going to be based on our medical decision-making, the complexity of that patient that's being discharged, and when our face-to-face is going to be scheduled.

And so we've just got a little bit more here. One of the things just to kind of be aware of is that the work RVUs for transitional care management is typically higher. And again, because of the work we're going to do kind of in between that visit and then the actual visit that the provider's going to have with the patient. So that RVU is actually higher and the date of the service will be then the date the patient has the face-to-face encounter.

We're going to talk a little bit about behavioral health integration. I think we've definitely have seen CMS do a lot with behavioral health, whether it be in our care management services, in our telehealth, we have permanent telehealth coverage for behavioral health. So we've seen a lot. So behavioral health integration is really that care management service for those behavioral health conditions. And similar to our chronic care management where we have that 20 minutes of clinical staff time that's directed by a provider per calendar month. And again, it's specific for the clinical staff that they're going to perform these services under the direction of the physician or the qualified healthcare professional.

So very similar, we're going to have that care plan, we're going to have staff checking in with that patient and again, trying to maintain that patient's health and uncovering things that might be happening that we wouldn't otherwise know until the patient came back into the clinic. So the code on that 99484, may be reported in any setting except inpatient or observation. Once it has to be an established relationship with the patient and then the clinical staff is available to be with that patient. The clinical staff time is really spent coordinating care sometimes with the emergency departments, but it cannot be reported if we're doing any care while they're an inpatient or an observation.

So if they coordinated some care with an ED, I think, Susan, that can be reported, right?

Susan Rohde: Yes, correct.

Joy Krush: It's just the inpatient or observation. That sentence is worded a little bit strange. So for new patients or patients not seen within a year, we are going to need to have a visit with the patient. It can be an E/M visit, it could even be an AWV or IPPE. But with any of these services, the provider does have to discuss those services that they're going to enroll the patient in. Similar would be that with behavioral health integration.

So, some required elements of BHI, the initial assessment or follow-up monitoring, including the use of applicable validated rating scales of that patient where their status is behavioral healthcare planning in relation to their behavioral psychiatric health problem. And that's going to be the same revisions for patients who are not progressing, their status is changing, coordinating care such as psychotherapy, pharmacotherapy, counseling, or maybe they need to get back in and see this psychiatrist. It's really that continuity of care with a designated member of the care team.

So, the other one we're going to touch on is collaborative care model. This one is kind of unique in that it's really behavioral health integrating with primary care and they're adding two key services to the primary care team, particularly for patients whose conditions aren't improving.

I think nobody would probably argue that patients that have maybe a chronic condition, CHF, COPD, multiple sclerosis, multiple things, right? If there is a behavioral health component to this, it is harder to manage sometimes that patient's chronic medical condition if we don't take also care of their behavioral health condition. And that is really where collaborative care model is coming into play. There's regular psychiatric interspecialty consultation, maybe they aren't actually seeing the psychiatrist that often, but we have that consultation with that patient. So, it's kind of a team of three that will deliver it. We have a behavioral health care manager and they're the designated provider with some formal education in behavioral health. So that could be social work psychology, psychiatric consultant, and that will be medical provider training and psychiatry. And they're able to prescribe the full range of medications. And then we're going to have our primary care provider, kind of our treating practitioner who has the primary care responsibility for that patient.

So, what are some of the components? So there's going to be that initial assessment. The primary care team assesses the patient and administers validated rating scales. There's joint care planning. So, the primary care team is going to work with the patient to revise the care plan if it isn't improving adequately. So again, same thing, that care plan, and we're going to revise that care plan as needed. And again, the treatments can be a variety of things. And then that ongoing follow up, and I think this is just the critical point here where we have that behavioral healthcare manager who is following up proactively, again using those rating scales to see where that patient is at. Assessing their treatment adherence, their tolerability, their clinical response. They may deliver brief evidence-based psychosocial interventions such as behavioral activation or motivational interviewing.

And they're going to provide 70 minutes of that behavioral healthcare manager time in the first month and then it goes down 60 minutes in the following months with some add-on codes in any of those months as needed.

Systematic case review, that behavioral healthcare manager and the psychiatric consultant are going to conduct caseload reviews. So that's where that psychiatrist gets pulled into this with the behavioral healthcare manager to really look at the treatment plan, their status. If they're not improving, what are potential revisions. And then the primary care team just continues to adjust treatment including referral to maybe they need specialty care as needed. So, it's really a three-prong approach involving the patient's primary care provider along with psychiatry, and behavioral care.

We do need advanced consent as well as Susan talked about consent and other things. Because we do want to make sure too when we're enrolling a patient in collaborative care model that they understand there's going to be other specialists involved, which includes talking with a psychiatric consultant. It can be verbal, but document in the record. And then there is cost sharing that applies. And that is something with any of the care management services that we talk about, we want to look at patient's understanding if they are going to have out-of-pocket responsibilities. That they're aware of that, that that's not a surprise because we don't want that to become a deterrent for the patient not using the service and be a patient complaint down the road. These are the codes for CoCM. So we have the initial, the first 70 minutes, the subsequent, the first 60 minutes, and then that additional 30 minutes. So, we have three codes in this category of the service.

There are some additional codes that have been added to. So in 2021, G2214 came out, and this is defined as initial or subsequent psychiatric collaborative care management. It's for 30 minutes. Services and consultation with the psychiatric consultant and directed by the treating physician.

When would we use this? Maybe we see a patient for services, then we hospitalize them or refer them to specialized care and we didn't meet the total number of minutes. This is a way that we could or be able to report that time with CPT code G2214. And in addition, we have G0323, which was added in 2023. That was introduced to describe behavioral health integration services that a clinical psychologist or a clinical social worker performs. It's that monthly care integration with the psychologist or clinical social worker serving as the focal point. It requires at least 20 minutes and there does have to be that initiating visit by a psychiatrist prior to these services.

So again, just as we can kind of see, CMS has expanded these behavioral health services and they've continued as we saw in 2021 now, in 2023 to continue to provide care management services for us to help address our mental health issues in our populations.

So advanced primary care management. When this one came out, we'll be honest, when Susan and I were looking at these codes, we were like, "Wow, this one is one or no chronic conditions, how does this work?" But I think it was then as we kind of talked through what was the intent behind this, and this really is to support our primary care physicians and their transition to value-based care.

So that is where I think the emphasis of these codes came out. There's no monthly minimum time requirements. Services provided by clinical staff and directed by a physician or other qualified healthcare professional. Again, who's responsible for primary care and they're going to be their focal point for these services.

Documentation standards similar to CCM, not all services must be provided each month and a minimum number of minutes of services not required, which we kind of struggle with from just how does that work? Because we're used to making sure we've got our time documented and that type of thing. But again, we would have to have some type of documentation.

I think one of the things that we kind of talked about and we've heard others maybe talk about is sometimes with CCM, we don't meet our total number of minutes. Maybe advanced primary care management could be that fill in if we're not able to meet those total minutes. The requirements are pretty similar. We have to have data 24/7 access, provide comprehensive care management. We have to have our care plan. Same requirements for APCM as well.

Our documentation, we have to coordinate care transition, coordinate a practitioner home community-based care, provide communication. Now, what is noted though that we also need to do is there does have to be some kind of patient population level management and measure and report performance. So if you're participating in MIPS, if you're participating in a shared savings program or an ACO, this is where APCM is really going to come into play as well if we are implementing this because then we can measure and report performance for these services.

So just some best practices for implementing care management that we're going to just touch on. Susan's touched on some of this as we talk about workflow. We want to have that training. It's not that we can just start these programs with making sure everybody's not sure what their role is.

We need to understand what the requirements are for billing the codes. RHIhub has great information. CMS really in their MLNs has provided great information. So the information is out there for us to really be able to get to help us with that. We do want that care plan and understanding that that care plan is not just a one and done. That that's a living, breathing document that is being updated. And then what are our documentation expectations for our staff? We really need to have that in place. Time tracking, clinical relevance, all of that of what we're expecting to be documented. How are we going to use our EHR templates and alerts.

Patient engagement techniques. And Susan touched on this, kind of tracking what's working for a patient and what's not and if they are not communicating with us via email, then we need to switch gears. And so we need to have that in our process plan to know that we're going to continue to look at that. And then I think those job aids or checklists, anytime we can have something for staff to be able to look at and help guide them, we're obviously going to be more successful in that.

So, we're going to want to use our EHR to its best of ability to track our time, record a care plan, set reminders for monthly follow-ups. One of the things that I know we've had conversations with clinics on is have it determined upfront when you're going to bill for these services. Are we going to do it when we meet our time for the service or are we going to wait until the end of the month? And we have some things to consider with that as well. If we're in the RHC, if we end up doing it on the day that we have a face-to-face. What does that look like? So things to think about, but let's make sure that we're consistent on that. Otherwise, if we're not consistent, I think we're going to miss billing or we possibly could do some over billing.

And do we have any dashboards to help us to manage this? Some EHRs have that. Some facilities have access to their ACO management tools, anything like that to help you track this certainly is going to be a positive for your organization.

And then I think don't try to boil the ocean if you're going to start out a program. Test the program, do a small group of patients that has seemed to work the best for clinics so they understand time management, patient response, billing success, understanding patient outcomes. I think one of the things that I know we've learned from some clinics is that.

So how are we going to incorporate into our provider's schedule reviewing that care plan? Are we going to block that out on their calendars each month so that they have X amount of time to look at their chronic care management patient load and review it maybe with whoever the care management team is and revise those care plans just so we have that set? Because if we just leave it to when they have time, they may not have time. So, setting that in your provider schedule is also a definite success point.

And then just monitor performance and adjust, right? What's the patient satisfaction? I mean, one thing we heard from some clinics again, and I mentioned it before, was making sure patients understand these care management services are not like preventive care. That's a hundred percent paid by Medicare, right? Oftentimes there are co-pays. Secondaries typically will pick that up, but just so everybody understands that. Were we able to decrease hospitalization or ER visits? If we're attached to a hospital, that is a success. If we have care management TCM and we're decreasing the amount of readmissions or revisits to the ED, obviously it's all about the patient. We want to meet their patient goals, get them to their best health possible. Medication adherence is huge, right? Making sure patients understand, yes, you need to take that at this time and how often in a day and making sure that those things are being done.

And then we just need to adjust staffing or workflow. Sometimes 10:00 in the morning's not going to be the right time to contact every patient. Maybe we need to do it later in the day if they're out and about during the day. So understanding those things and making sure we have that kind of understood of how our workflow is going to work. And we've already talked about the communication preferences and are we doing any duplication of efforts just looking at our performance and adjust those.

And then do a chart review. So if you start out with those 10 to 20 patients, then do a chart review. Do we meet all the things that CMS requires? Consent, we have the chronic conditions documented, we have a clear documentation of activities that were performed, the time that was spent. Just do that follow up. And then from then, once we feel like we have a good process down, as with anything, we should do periodic checks to make sure, especially if we've got new staff coming in to do these services, making sure we've got that documentation to meet our billing compliance.

And then once things are working, we want to expand and grow our care management. Definitely the social drivers of health are going to drive some of this. What are the things that are affecting our patients that care management services can help?

Telehealth is permanent for behavioral health. It's still until September 30th. For Medicare for medical, hopefully that goes beyond, is that something we can do? Would that work for our patient? Maybe they're savvy. Maybe we could get them to a telehealth visit versus getting them back in the office, but we can have those conversations with that care management team and then connecting them to community resources.

Susan, I think I'm going to let you jump in on this one because you do the best with understanding this G code for social drivers of health.

Susan Rohde: Absolutely. And I noticed there was quite a few questions in the Q&A, so I was answering them as I could. And then when we're done, we can go back to some and if we don't have time or don't have the particular answer, we can always email them to the staff at NORC and RHIhub and they can get those out to you.

So, when we are talking about the social drivers of health risk assessment, there is a HCPCS code for that, G0136. And the requirements here are that you have to utilize a standardized assessment tool. If you don't want to recreate the wheel and come up with one of your own that is standardized and evidence-based, Medicare does already have one out there, and you can just Google the PRAPARE tool.

So it's the word prepare except with an P-R-A-P-A-R-E tool or there is an accountable health communities tool, the AHC tool. Again, you can simply Google that. If you were to make your own tool, it does need to address at a minimum, food insecurity, housing insecurity, transportation needs, and utility difficulties. It has to touch on those four social drivers of health. What this is, it's not really a screening, it's an assessment. So we're assessing these patients to see if they identify with one of those four areas of food insecurity, housing insecurity, transportation needs, and utility difficulties.

And this does have to somehow get over into your official medical record. This can be assigned and... Well, you can assign it as much as you want, but you can get reimbursed on it every six months. You do not have to have any sort of documented consent in order to administer this assessment tool. As of right now though, it's important to note that CMS did not add this risk assessment, this GO136 to their list of general care management services that RHCs and FQHCs can be reimbursed for. So that's important.

RHCs and FQHCs as of right now will not receive any additional reimbursement for performing this GO136, the social driver of health risk assessment form. Again, you probably are already utilizing this in some way, shape, or form at your facility already, but if you don't want to make up your own tool, Google the PRAPARE or the AHC tool and you can just go from there as long as it makes it into your documentation in your EMR.

Kristine Sande: Thanks so much. That was really informative. At this point, we will take questions. So what outreach techniques do qualified patients have you found to be effective and what in-office workflows for warm handoffs for case management services have worked best?

Joy Krush: I think for the outreach techniques, I really think it comes back to the primary care provider the patient has because that usually is who they're going to look to. So I think first off is educating our providers about these programs and what the benefits are because they obviously have to buy into it as well, and then if... Because they're going to be the ones that really know that patient well and have that conversation with the patient. So I would say, Susan, that would be the best outreach that I have seen would be the primary care provider.

Susan Rohde: I would agree with that. And then when we break it down a little bit more, really, those peer support specialists and those patient navigators, especially if it is something that they've been involved with in their own lives. It just works a little bit better than maybe... And especially if they're local to your community, then they're going to know more of the resources that are available, maybe have better access, can get the patients this access. That's typically what we've been seeing in some of the rural areas.

Kristine Sande: So, the requirement for PCM states “care management services personally provided by physician or NPP,” does that mean that auxiliary personnel is not counted and what specific activities of the physician NPP is provided and counted?

Susan Rohde: So those codes do have another subset of codes that are for if only clinical staff provides that service. But what we run into in like the RHC is then there is not that face-to-face by the provider. So we did not include those codes in this presentation. Auxiliary staff is able to perform certain components of all of these codes, just they cannot initiate the care plan that has to be done by the physician. And then anything sort of related to that clinical aspect does have to be performed by that physician or that mid-level. But patient outreach such as phone calls, helping schedule appointments, etc., that can all still be done by auxiliary staff.

Kristine Sande: All right. Next question is, "We are a certified community behavioral health clinic and certified mental health clinic. Are any of these CPT codes and services available to us for billing through Medicare?"

Joy Krush: I mean for Medicare, I would think the BHI, of course, that requires primary care too. I know when we were talking about this with the CCBHC, we did kind of talk about how possibly could this be done in conjunction with a clinic setting, getting that primary care provider involved. So I think it would maybe be looking at do we have primary care in conjunction with that?

Susan Rohde: Are you affiliated with an RHC?

Joy Krush: Or do you have some type of a clinic setting that you're affiliated with?

Kristine Sande: How do you gain buy-in for services given the copay amounts due, or are there wraparound insurances that cover the copays, other financial support for seniors who can afford this additional level of care?

Joy Krush: I mean, I think this comes down to if they've got a, which a lot of Medicare patients do have, a secondary, or they may have Medicaid secondary. So I think making sure that that conversation when we're having that co-insurance conversation, is it truly going to be their out-of-pocket or will their secondary pick it up? Is there financial support to afford this additional? That I'm not aware of outside of our traditional insurance plans being our secondary or Medicaid secondary.

Susan Rohde: And the way to sort of get the buy-in is to just really promote the benefits because it'll keep you from admitting to the hospital, which we know would be a much higher cost to both patient and facility. So that's typically how we've been seeing it, just trying to really push for promoting the benefits of the program.

Joy Krush: One thing I'm just going to add, and I know this is a little bit off-topic from the question, but I think one of the things we're seeing kind of explode in all of our clinic settings are patients' use of MyChart or messaging to providers. I mean, providers are spending a considerable amount of time answering questions. And while we could go into a whole other topic about there are some virtual care codes that can be reported, but there's a lot of rules behind them. If we do some of these care management things where we've got a case manager having conversations with the patient, would that cut down on some of that provider time of having to answer questions?

Just a thought too because that is one thing I'm getting a lot of questions on. Is clinics talking about the amount of provider time that are spending on that, and if they're not able to bill anything, so we've just talked about, well, what if they were in chronic care management? Could some of that have been offloaded and the case manager could have handled that? Had the patient known that, but all they know is their provider to reach out to.

Kristine Sande: Should an FQHC use the G0136 code when administering the PRAPARE tool, even though they're not reimbursed for the service?

Susan Rohde: We're always about assigning the code, if the documentation supports, even if you're not going to be reimbursed, this is not going to cause any sort of denial or a claim by denial. What I would worry about here though, is this going to have any sort of financial impact on the patient? Is any of this going to go towards patient responsibility or towards our copay or towards their deductible? That would be the only thing that I would want to bring into question.

Kristine Sande: For any of the services as well as peer support, are they only billable on a UB-O4 claims form?

Joy Krush: Are they only billable? So we must be talking like a RHC. I mean, these would be billable on a 1500 if we were in a freestanding clinic. So I would say no to that.

Susan Rohde: Yes or no, they can be on a 1500 if site specific.

Kristine Sande: So next question is, "We are a county public health department with a clinic, but it is not a primary care clinic. Are we eligible to provide care management services?"

Susan Rohde: Wondering... So they have a clinic, but it's not a primary care clinic, but is that necessarily a designation? So are we eligible to provide care management services? I would not see why not? Because there isn't anything with chronic care management that says you have to be of this particular specialty to assign it.

Joy Krush: I think one thing you would have to be cautious of is that, and we have run into this where, patients can't be enrolled in two clinics. So if they're being seen somewhere else with a primary care provider, have they enrolled them in chronic care management? I think that would be the thing that we'd have to be-

Susan Rohde: ... or the COCM. I do think there is a requirement of a primary there, but first-

Joy Krush: You're right. Because that's that three prong approach, and that has very specific providers or very specific requirements.

Kristine Sande: Is there a requirement for the provider to document ongoing input on the care plan after initiation with these, such as every three months or six months?

Susan Rohde: I don't know if there's anything in black and white from Medicare that says it. This will just all boil down to probably patient care and what your particular facility is going to have for a policy for updating it. Obviously, if something changes with the patient, you definitely want to get that down, but there isn't anything from Medicare that says every three months you have to do this.

Joy Krush: No. And the CPT just says, "Care plan established, implemented, revised, or monitored." I mean, we just want to make sure we don't just do a care plan and that we have some kind of a process in place.

Susan Rohde: Like a follow-up. Kristine, I love this next one.

Kristine Sande: So, do you all feel it's best to utilize a third party to handle CCM for a starting point?

Susan Rohde: So, a third party can be great, necessary to help you. What I do want to do is just throw out some caution there that you really do your due diligence when you are vetting out some of these third parties. What we have seen in our experience is that a lot of these third parties aren't necessarily familiar with RHC structures requirements as far as coding and billing, etc., and just seeing a lot of maybe over-promising and under-delivering with some of these companies. And it's been on the uptick.

So I would just want... If it sounds maybe too good to be true, it potentially could be. So please just really do your due diligence when you're looking at these third parties. We have done quite a few reviews for facilities that have gone to third parties just within the last year. So I know that there is an uptick in utilizing them. But again, just make sure you're doing all your homework there.

Joy Krush: And remember that the potential of who's contacting this patient is not going to be in your community. And that I think can be kind of a disadvantage maybe.

Susan Rohde: Because the patients definitely think it is someone from ABC Local Hospital calling them, and that is not the case.

Kristine Sande: Right. So this one says, "We are an MHOTRS clinic. Could we bill for these services?" So that's mental health outpatient treatment and rehabilitative services.

Susan Rohde: Thank you, Kristine. I was racking my brain on that one. If you have the correct sort of providers and the documentation is there, I have not seen anything saying you could not. Again, there are no requirements for a specialty for CoCM PCM. So who's to say the chronic condition wasn't something surrounding mental health. Now with that being said, would you be more apt to go towards the BHI and the CoCM? Probably.

And we do know that those are going to require that primary care component, but again, principal care management, there is nothing in there to say that the condition has to be cancer, etc. You just have to fall within those parameters. Is it for chronic care management? Is it two chronic conditions that are going to last at least 12 months or until the death of the patient?

Kristine Sande: All right, and last question. What are the requirements for 24/7 availability for a PCM? Does the PCP have to be on call all the time or the clinical staff?

Joy Krush: My thought on this, and this is really with any of these care management services, is that typically what we see is that, again, kind of when we're establishing that care plan. That we have the conversation with the patient that... Because typically we're close to a hospital setting and they have got an ER, and they're going to be accessible, and that we have provided that information to those facilities. That is oftentimes what we would see that that's accessible by the hospital.

Not that we're going to have somebody out of the clinic sitting on call all the time. I mean, every clinic is going to have a little bit of different setup on how this works. I would say whatever your practice is for patients even just calling in because their primary care provider. If they're directed to go to the ED, it would be that same kind of thing. What would you say, Susan?

Susan Rohde: I agree with that because obviously you're not going to have one provider 24/7

Kristine Sande: All right. Thanks so much. So that brings us to the close of our webinar. On behalf of the Rural Health Information Hub, thank you so much to our speakers for this great information and the insights that you've shared with us today. Also, a big thank you to all of our participants for joining us. The slides that were used in today's webinar are currently available on the RHIhub website at https://www.ruralhealthinfo.org/webinars. In addition, recording and a transcript of today's webinar will be made available on the RHIhub website. Thanks so much for joining us and have a great day.

Susan Rohde: Thank you.

Joy Krush: Thank you. Bye.