Can We Contract Out Chronic Care Management Services?

Q. Under the Medicare Chronic Care Management (CCM) Services program, can my practice subcontract CCM services to a case management company? What if the clinical staff the case management company employs is located outside the United States?

A. You may arrange to have clinical staff external to your practice, such as a case management company, provide CCM services if you meet all the “incident to” and other rules for billing Medicare for these services. However, because there is a regulatory prohibition against payment for nonemergency Medicare services furnished outside the United States, you can’t bill Medicare for CCM services if they’re provided to patients or by individuals located outside the country.

If you use an outside management company, you, as the billing physician, still must initiate the CCM during a “comprehensive” evaluation and management (E&M) visit, annual wellness visit (AWV), or initial preventive physical exam (IPPE).

This face-to-face visit is not part of the CCM service, and you can bill Medicare for it separately, but it’s required before you can provide CCM services directly or under other arrangements. You must discuss CCM with the patient at this visit, and while you don’t have to obtain informed patient consent during this visit, it is an opportunity to do so.

The face-to-face visit included in transitional care management (TCM) services (CPT 99495 and 99496) qualifies as a “comprehensive” visit for CCM initiation. Levels 2 through 5 E&M visits (CPT 99212 through 99215) also qualify. However CPT codes that don’t involve a face-to-face visit by the billing physician or are not separately payable by Medicare (such as CPT 99211, anticoagulant management, online services, telephone, and other E&M services) do not meet the requirement for the visit that must occur before you furnish CCM services. If you furnish a “comprehensive” E&M, AWV, or IPPE but don’t discuss CCM with the patient at that visit, that visit can’t count as the initiating visit for CCM.

See more answers in the Centers for Medicare & Medicaid Services’ FAQs about billing Medicare for CCM. This is one of many resources on CMS’ new Care Management webpage that covers advance care planning, CCM, and TCM. 

Published Feb. 7, 2017

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Last Updated On

November 22, 2019

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