The OIG recently released a report that found CMS has continued to make overpayments for Chronic Care Management (CCM) services despite prior audit report findings and ongoing recommendations made to CMS. 

In their most recent audit, the OIG found that CCM services (both complex and non-complex) did not meet Medicare billing requirements.  The OIG report identified over $1.9 million in overpayments. CCM services are also on the OIG Work Plan.

Additionally, the 2020 Medicare Fee-For-Service Supplemental Improper Payment Data, identified a 67.4% improper payment rate for CCM services.

THE FINDINGS

The overarching errors were related to:

• Multiple claims that were billed by a single provider within the same month
• Claims submitted by more than one provider within the same month
• Claims submitted for CCM services that overlapped with other care management services
• Incremental complex CCM services (each additional 30-minutes) that were billed along with complex CCM

The OIG indicated these errors occurred because CMS did not have claims system edits in place to prevent and detect overpayments.  Furthermore, they did not have CCM specific system edits in place.

THE BILLING REQUIREMENTS

Medicare provides reimbursement for CCM services when certain criteria are met which include:

• Providing at least 20 minutes per month of non-face-to-face services for non-complex CCM (CPT codes 99490-99491) and at least 60 minutes for complex CCM (CPT codes 99487 and 99489).
• Medicare beneficiary has two or more chronic conditions expected to last at least 12 months
• The chronic conditions place the beneficiary at a significant risk of death, acute exacerbation, decompensation or functional decline
• Services may only be billed once per month, per beneficiary
• Only one physician and one facility may bill for CCM services each month per beneficiary
• CCM may not be billed in addition to transitional care management, home health or hospice supervision or ESRD supervision services
• Must obtain beneficiary consent to provide and bill Medicare for CCM services
• Physician must use a certified EHR system
• Complex CCM services also require moderate or high complexity medical decision making as well as establishment or substantial revision of a comprehensive care plan

OUR RECOMMENDATIONS

We recommend conducting auditing and monitoring of your CCM services to ensure compliance with the billing requirements outlined by CMS.  HBE’s team of coding and compliance experts is available to assist you external reviews of your documentation, coding and reimbursement as well as providing customized education and training for your staff.  We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development. 

The OIG Report is available here: https://oig.hhs.gov/oas/reports/region7/71905122.pdf

A summary of CCM Medicare Requirements is available here:  https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf

DISCLAIMER:  This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel