Chronic care management services provided by independent contractor

June 10, 2017

Can Medicare be billed for third-party chronic care management services?

Q: Our group would like to contract with an independent care management company to provide chronic care management (CCM) services to our patients with multiple chronic conditions. Our physician would establish the care plans for our patients and provide general supervision of the clinical staff employed by the care management company. Can we bill Medicare for these services?

A: The Centers for Medicare & Medicaid Services (CMS) has indicated that as long as the “incident to” and all other billing requirements are met, providers may bill for the CCM services that they contract out to independent companies. 

Note:  CMS provides an exception under Medicare’s “incident to” rules that permits clinical staff to provide CCM services under the general supervision (rather than direct supervision) of the billing provider. General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure or service.

Q: Can you explain “mutually exclusive edits”?

A: The mutually exclusive edits, which used to be in a separate table but are now in the column 1 /column 2 code edit table, consist of two procedure codes that cannot reasonably be performed together based on the code definitions or anatomic considerations. 

Each edit consists of a column 1 and column 2 code. If the two codes of an edit are billed on the same date of service for the same patient by the same provider without an appropriate modifier, only the column 1 code is paid. If clinical circumstances justify using an appropriate modifier to the column 2 code, payment of both codes may be allowed.

Q: Can a physician receive credit for performing the History of Present Illness (HPI) component of an Evaluation and Management (E/M) service if a staff member-nurse or medical assistant-takes the HPI and then presents the information to the physician in the presence of the patient?

A: According to the 1995 and 1997 Evaluation and Management Guidelines, only the physician or non-physician practitioner (NPP) who bills the service may take the HPI. Team members can obtain the review of systems and past, family and social history components, as well as record the chief complaint if the physician also validates it. 

However, the physician does not “take ownership” of the HPI simply because the team member who actually documented the information presents it to the physician in the presence of the patient.