Chronic Care Management (CCM) is Now a DOJ Enforcement Priority - Healthcare Fraud Defense Firm
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Chronic Care Management (CCM) is Now a DOJ Enforcement Priority

CCM is now DOJ enforcement priority

Chronic care management (CCM) is a relatively new concept within the Medicare system. Established in 2015, the Centers for Medicare and Medicaid Services’ CCM program is aimed at reducing the cost of care and improving outcomes for patients who have been diagnosed with two or more chronic conditions. While the Centers for Medicare and Medicaid Services (CMS) relaxed some of the rules and regulations for CCM billing in 2017, compliance challenges remain, and providers that bill Medicare for CCM services must ensure that they are doing so properly.

Recently, enforcing compliance with regard to CCM billing has become a priority for the U.S. Department of Justice (DOJ). We have now seen multiple cases of providers facing investigations focused on CCM compliance. As a result, while providers must take adequate measures to ensure compliance generally, it is now more important than ever for providers to avoid miscues with regard to their billings for chronic care management services.

Understanding Chronic Care Management and the Billing Rules for CCM

There are several important aspects to CCM billing compliance. First we’ll cover what providers need to know about compliance, and then we will provide an overview of the core components of an effective CCM billing compliance program.

Chronic Care Management Defined

Chronic care management has a specific definition under the Medicare billing rules. In order to bill for CCM providers must ensure that they are in fact providing “chronic care management,” and they must ensure that both they and their patients are eligible. The Centers for Medicare and Medicaid Services define chronic care management as follows:

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Lynette S. Byrd
Lynette S. Byrd

Former DOJ Trial Attorney


Brian J. Kuester
Brian J. Kuester

Former U.S. Attorney

Amanda Marshall
Amanda Marshall

Former U.S. Attorney

Local Counsel

Joe Brown
Joe Brown

Former U.S. Attorney

Local Counsel

John W. Sellers
John W. Sellers

Former Senior DOJ Trial Attorney

Linda Julin McNamara
Linda Julin McNamara

Federal Appeals Attorney

Aaron L. Wiley
Aaron L. Wiley

Former DOJ attorney

Local Counsel

Roger Bach
Roger Bach

Former Special Agent (DOJ)

Chris Quick
Chris J. Quick

Former Special Agent (FBI & IRS-CI)

Michael S. Koslow
Michael S. Koslow

Former Supervisory Special Agent (DOD-OIG)

Ray Yuen
Ray Yuen

Former Supervisory Special Agent (FBI)

“Chronic care management is care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These services are typically non-face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month.”

“Care coordination services” include things like helping patients understand their doctors’ recommendations, managing their care plans, and making sure they take the right medications at the right times. These services are typically provided over the phone, and often involve calls lasting only a few minutes. Over the course of a month, however, these minutes can add up, and the CCM billing rules are designed to ensure that both (i) patients can get the information they need to manage their care, and (ii) providers are able to bill for providing this information to their patients on an as-needed basis.

So, why is the DOJ prioritizing CCM billing compliance? The DOJ views chronic care management as having a high risk for fraud. In particular, the DOJ is focused on providers overstating the amount of time they spend providing CCM services so that they can bill Medicare for services not actually provided or for services that do not meet the threshold time requirements.

Eligible Healthcare Practitioners

Another issue that has come up in some cases is the issue of providers billing for CCM services rendered by ineligible practitioners. Under the Medicare billing guidelines, providers may only bill for CCM services provided by:

  • Certified nurse midwives
  • Clinical nurse specialists
  • Nurse practitioners
  • Physician assistants
  • Physicians (including primary care doctors and specialists)

In some cases, time spent providing chronic care management services by clinical staff can count toward a billing physician’s time. However, this is specific to certain CPT codes. If a provider bills for ineligible clinical staff time, this can also lead to an investigation (and possible penalization) for Medicare billing fraud.

Eligible Patients

Providers can only bill Medicare for chronic care management services they provide to eligible patients. A patient is generally considered eligible for CCM services if:

  • The patient has two or more chronic conditions that are expected to last at least 12 months or until the patient’s death; and,
  • The patient’s chronic conditions place him or her, “at significant risk of death, acute exacerbation/decompensation, or functional decline.”

The Centers for Medicare and Medicaid Services list the following as non-exclusive examples of chronic conditions that may qualify a patient for CCM services:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular Disease
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS

However, prior to billing Medicare for CCM, providers must ensure that their patients qualify—simply having two or more of these conditions is not enough. A patient must satisfy both of the eligibility criteria listed above—and this means that providers must make a specific determination as to the risks associated with each individual patient’s chronic conditions.

Common CPT Billing Codes for Chronic Care Management

There are four CPT codes that providers can use to bill Medicare for CCM. This includes two codes for “complex CCM,” which providers must bill separately (“[a] practitioner must only report either complex or non-complex CCM for a given patient for the month (not both)”). The CPT codes used to bill for chronic care management services are:

  • CPT Code 99490 – Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (assumes 15 minutes of work by the billing practitioner per month).
  • CPT Code 99491 – Chronic care management services, provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified healthcare professional time, per calendar month.
  • CPT Code 99487 – Complex chronic care management services involving establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making, and 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
  • CPT Code 99489 – Each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.

Common CCM Billing Compliance Issues

When billing Medicare for chronic care management services, healthcare providers must be careful to avoid a number of mistakes. Some of the most common CCM billing compliance issues (that can lead to trouble during DOJ investigations) include:

  • Patient Ineligibility – Providers must confirm patients’ eligibility for CCM services prior to billing. This must be done during a face-to-face “initiating visit,” which providers should bill separately.
  • Lack of Patient Consent – Providers must obtain a patient’s consent prior to providing (and billing for) CCM services. Providers should maintain documentation of their patients’ consent to CCM services on hand, and this documentation should make clear that the patient received an explanation of the services and was given the option to decline.
  • Inadequate Documentation – Like all types of Medicare billings, providers must maintain comprehensive documentation to substantiate their CCM billings. This includes documentation of patient eligibility, patient consent, and the services rendered and billed on a monthly basis.
  • Billing for Ineligible Practitioners or Staff – Providers must ensure that they only bill for CCM provided by eligible practitioners and staff. As noted above, with regard to staff, eligibility requirements can vary depending on the CPT code used.
  • Inflating Time Spent Providing CCM Services – All of the CPT codes for CCM services require providers to spend at least a minimum amount of time each month providing services to an eligible patient (either 20, 30, or 60 minutes depending on the code used). Inflating time spent in order to bill for CCM is considered a form of Medicare billing fraud.
  • Billing for NonComplex and Complex CCM in the Same Month – Providers cannot bill for both non-complex and complex CCM for the same patient in the same month. Doing so is a red flag that can trigger scrutiny from CMS and/or the DOJ.

What Can (and Should) Providers Do to Avoid CMS and DOJ Scrutiny With Regard to CCM Billing?

Given the intricate compliance obligations for CCM billing and the risks of billing non-compliance, what can (and should) providers do to avoid issues with CMS and the DOJ?

1. Develop CCM-Specific Billing Policies and Procedures

Healthcare providers should develop billing policies and procedures that are specific to CCM. These policies and procedures should touch on all aspects of compliance—from patient and practitioner eligibility to documentation and CPT code selection.

2. Provide Education and Training to Relevant Personnel

Once providers develop CCM-specific billing policies and procedures, they should provide adequate education and training to all relevant personnel. This includes practitioners who provide CCM services, medical staff who provide CCM services, and billing administrators.

3. Monitor, Audit, and Enforce CCM Billing Compliance

Finally, providers that bill Medicare for CCM services must monitor, audit, and enforce their compliance programs on an ongoing basis. They should have clear and documented protocols for conducting monitoring and audits, and they should have established guidelines for addressing instances of noncompliance.

Speak with a Medicare Billing Compliance Lawyer at Oberheiden P.C.

Do you have questions or concerns about your practice’s CCM billing policies and procedures? If so, we encourage you to speak with a Medicare billing compliance lawyer at Oberheiden P.C. To schedule a complimentary consultation at your convenience, please call 888-680-1745 or inquire online today.

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