NAMAS Webinar Q&A: TCM & CCM: What You Need to Know

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Below are the questions received during our recent webinar, TCM & CCM: What You Need to Know, originally presented on May 14, 2019. These questions have been answered by the webinar presenter, Aimee Wilcox, CPMA, CCS-PCST, MA, MT.

Also, here is the link to the CCM FAQ that Aimee referred to in the webinar:
https://www.cms.gov/Medicare/Medicare-F ... es_FAQ.pdf

Question 1:
Is it possible for the nursing staff to render CCM services. Or must they be registered to practice as Clinical Nursing Specialists?
Answer 1:
CMS policy identifies these three nurse types and physician assistants as eligible to bill CCM services: see document at https://www.cms.gov/outreach-and-educat ... gement.pdf

This indicates they must be Clinical Nurse Specialists (CNS).

Practitioner Eligibility:
Physicians and the following non-physician practitioners may bill CCM services:
Certified Nurse Midwives
Clinical Nurse Specialists
Nurse Practitioners
Physician Assistants

Question 2:
You are a wonderful presenter. You mentioned that you have quite a bit of info on Telemed rules that you could share.. I would very much like to know more.
Answer 2:
I am actually presenting at the Utah Department of Fraud next Tuesday on Telemedicine and will be recording the presentation prior to it to sell on at findacode.com. Telemedicine is a rapidly expanding area of medicine with state laws and payer policies constantly changing, so keeping up to date is very important. If you sign up for a free 28-day trial at findacode.com, you can access prior webinar presentations we've done and my counterpart, Wyn Staheli, Director of Research, did a Telemedicine webinar I believe in November that contains quite a bit of information. A 28-day free trial doesn't require a credit card and isn't followed by tons of email or phone calls trying to pressure you into a regular subscription. Someone may call you to show you how the site works (it is seriously like being a kid in a Wonka Chocolate Factory where there are so many things to do and check out you simply may need some assistance navigating is all).

Feel free to check out that resource in past webinars by signing in and going to Community, Webinars 30-60 minutes and searching Telemedicine. If you'd like even more information, the one I am recording will be on sale soon too. We also have several articles on our website, which you can search through the topic pages.

A good resource for state policies is: http://www.fsmb.org/siteassets/advocacy ... _state.pdf

Question 3:
Very informative! You stated to email you regarding information on telehealth services. I would appreciate any information you have.
Answer 3:
I am actually presenting at the Utah Department of Fraud next Tuesday on Telemedicine and will be recording the presentation prior to it to sell on at findacode.com. Telemedicine is a rapidly expanding area of medicine with state laws and payer policies constantly changing, so keeping up to date is very important. If you sign up for a free 28-day trial at findacode.com, you can access prior webinar presentations we've done and my counterpart, Wyn Staheli, Director of Research, did a Telemedicine webinar I believe in November that contains quite a bit of information. A 28-day free trial doesn't require a credit card and isn't followed by tons of email or phone calls trying to pressure you into a regular subscription. Someone may call you to show you how the site works (it is seriously like being a kid in a Wonka Chocolate Factory where there are so many things to do and check out you simply may need some assistance navigating is all).

Feel free to check out that resource in past webinars by signing in and going to Community, Webinars 30-60 minutes and searching Telemedicine. If you'd like even more information, the one I am recording will be on sale soon too. We also have several articles on our website, which you can search through the topic pages.

A good resource for state policies is: http://www.fsmb.org/siteassets/advocacy ... _state.pdf

Question 4:
Can we clarify if a CCM staff member can write the comprehensive care plan, with data pulled from the MD’s initiating visit?
Answer 4:
Care plans should be written by the billing provider only, not clinical staff.

Question 5:
If a staff member discusses a condition and it is not noted on the Comprehensive Care Plan, should she be billing for this diagnosis?
Answer 5:
If the diagnosis is acute, it should be addressed with the provider in a regular Evaluation and Management service and reported with a code that represents the location and type of E/M service. If the diagnosis is a chronic condition that is not already addressed as part of the chronic care management plan, it should be directed to the provider to determine if it needs to be added to the CCM plan, which would then allow it to be reported

Question 6:
If a new condition arises, can the CCM staff update the Comprehensive Care Plan and the MD sign.
Answer 6:
No. New conditions must be directed to the provider for management decisions and documentation and any changes to the CCM plan must be documented by the billing provider. Additionally, the condition itself must meet the specific CCM criteria of chronicity expected to last at least 12 months or until the death of the patient and that places the patient at moderate or high risk of death, acute exacerbation/decompensation, or functional decline.

Question 7:
Are you able to explain the TCM and CCM being charged in the same month?
Answer 7:
Here are two FAQ Q&A responses by CMS addressing this question:

Question: CCM and transitional care management (TCM) cannot be billed during the same month. Does this mean that if the 30-day TCM service period ends during a given calendar month and a qualifying amount of time is spent furnishing CCM services on the remaining days of that calendar month, CCM service codes cannot be billed that month to the PFS?
Answer: The CCM service code(s) could be billed to the PFS during the same calendar month as TCM, if the TCM service period ends before the end of a given calendar month, a qualifying amount of time is spent furnishing CCM services subsequently during that month, and all other requirements to bill CCM are met during the remainder of the month

Question: During the 30 day period of TCM, can other medically necessary billable services be reported?
Answer: What about chronic care management services? Other reasonable and necessary Medicare services may be reported during the 30 day period, with the exception of those services that cannot be reported according to CPT guidance and Medicare HCPCS codes G0181 and G0182. CCM could be billed to the MPFS during the same calendar month as TCM only if the TCM service period ends before the end of a given calendar month, at least 20 minutes of qualifying CCM services are subsequently provided during that month, and all other CCM billing requirements are met. However, we expect that the majority of the time, CCM and TCM will not be billed during the same calendar month

Question 8:
Can we charge for minor procedures with TCM & if so what are the limitations?
Answer 8:
The following CMS FAQ Q&A may provide insight

Question: During the 30 day period of TCM, can other medically necessary billable services be reported?
Answer: What about chronic care management services? Other reasonable and necessary Medicare services may be reported during the 30 day period, with the exception of those services that cannot be reported according to CPT guidance and Medicare HCPCS codes G0181 and G0182. CCM could be billed to the MPFS during the same calendar month as TCM only if the TCM service period ends before the end of a given calendar month, at least 20 minutes of qualifying CCM services are subsequently provided during that month, and all other CCM billing requirements are met. However, we expect that the majority of the time, CCM and TCM will not be billed during the same calendar month

Question 9:
Did you say TCM can be done after ED visit?
Answer 9:
No. TCM services can only be initiated following discharge from one of the following settings:
• Inpatient acute care hospital
• Inpatient psychiatric hospital
• Long-term care hospital
• Skilled nursing facility
• Inpatient rehabilitation facility
• Hospital outpatient observation or partial hospitalization
• Partial hospitalization at a community mental health center
WHEN the patient is being returned to their community setting (home, domiciliary, rest home, assisted living, etc.) and not to another type of admission (location listed above).
If the patient was admitted from the ED to Observation and then discharged from observation to their community setting, it would qualify, but not when they were seen in the ED alone without admission to an Observation or Inpatient setting.

Question 10:
If a patient cancels an appointment for F2F, can that be considered to affect the 7 and 14 days timeframe for coding/billing?
Answer 10:
If the 2-day initial contact took place and the patient scheduled a follow-up face-to-face encounter with the provider and then failed to show up or canceled the appointment, and didn’t make a new appointment within the 7-14 day timeframe, it cannot be counted towards TCM services. However, the normal practice policy for failed or canceled appointments can be followed.

Question 11:
Question concerning Moderate MDM vs High MDM. If the patient is seen for face to face within the 7 days and at visit today, they are Moderate MDM, I am having problems explaining that just because they see the patient within the 7-day window, does it automatically qualify for 99496?
Answer 11:
All criteria for each code must be met to bill the specific code:
- 99495 communication within 2 business days following discharge, face-to-face encounter within 14 days of discharge, and moderate complexity MDM
- 99496 communication within 2 business days following discharge, face-to-face encounter within 7 days of discharge, and high complexity MDM

I would explain that a close look at the discharge summary should give some indication as to the severity of the patient’s condition; however, scheduling all TCM patients for their face-to-face encounter within 7 days helps guarantee the criteria have been met for any that may be assumed as moderate but actually turn out to be high severity MDM.

Question 12:
When the patient comes in for a CCM visit, if the patient has any other acute problem currently going on, how will that issues be taken care of and be billed? Does the patient need to come back again?
Answer 12:
When a CCM encounter reveals a new, acute problem that needs medical attention, the provider may perform an E/M service to address it during that same encounter. The E/M service is then reported separately and only the information used to evaluate the acute condition can be used to determine the E/M level of service. No double dipping of the key components can take place. It is suggested that a separate note or section of the documentation be used to address the acute condition; however, coders may review the documentation and separate the key components from the CCM service to determine the overall level of E/M for the acute condition. It would be rare for an acute condition evaluated at the time of a CCM encounter to be reported at a high level of E/M service.

Question 13:
Any recommendations for a preformatted Patient consent for CCM?
Answer 13:
Not anything specific; however, I would create a document that explains to the patient (in writing) the following:
- What is CCM?
- What are the benefits of CCM?
- Notice that deductible and co-insurance applies to these services
- The patient can only contract with one provider to perform CCM services
- If any acute conditions arise during the CCM period, those will be handled with a separate E/M encounter but can be performed at the same encounter as the CCM service and deductibles/co-insurance will apply
- I would ask the patient the following or have it in writing
- Do you have any questions?
- Do you agree to receive CCM services?
- Do you understand the insurance will apply deductibles and coinsurance?
- How do you wish to be contacted (e.g., phone, email, text) and at what time?
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