CAPPRE Primary Care Pharmacy Practice Collaborative��April 2025 Session��

ISU L.S. Skaggs College of Pharmacy

Center for Advancing Pharmacy Practice and Research Excellence (CAPPRE)

Agenda

• Welcome
• Community Practice Highlight
• Chronic Care Management Discussion
• Open Discussion

Welcome and Introductions

• Please add your name and practice site to the chat

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• ISU Staff:
• Primary Care Practice Section Lead:
• Jordin Millward, PharmD, BCPS, CDCES

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• CAPPRE Director:
• Zach Rosko, PharmD, BCPS

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• CAPPRE Intern:
• Mikayla Antonson, PharmD Candidate

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Community Practice Highlight:�

Alex Lystrup�Pharmacy Manager, Primary Care �St. Luke’s Health System

Care Management Services

Zach Rosko, PharmD

Outline

• Introduction to Care Management Services
• Coding CM CPT Code
• Medicare Criteria for CCM and PCM
• Documentation Standards
• Diabetes Standards of Care
• Pharmacist's Role in Diabetes Management within CCM and PCM
• Resources and References

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Introduction to Care Management Services

Care Management Services

• Care Management (CM) services are a broad assortment of management and support services that are a critical component of primary and specialty care delivery
• Designated medical benefit category under Medicare and often Commercial and Medicaid plans
• Reportable and reimbursable service with designated AMA CPT codes:
• Chronic Care Management (CCM)
• Complex Chronic Care Management (CCCM)
• Principal Care Management (PCM)

• CM services generally fall within the scope of practice of pharmacy, and are an established model of pharmacist-PCP team based care
• CM service CPT codes are defined as team based services, and are intended to reimburse for the time of non-physician time spent under the general supervision of the physician or provider reporting the code
• To report CM CPT codes to any payer, the content of the service delivered must meet the AMA CPT coding standards for the codes, CPT guidance must be followed, documentation standards met and medical necessity must be established.
• To bill report these codes to Medicare, CMS requirements must be met in addition to CPT guidance

AMA CPT Overview of Care Management Services

• A type of Evaluation and Management Service (found in the E&M Chapter of the CPT Manual)
• Defined as management and support service provided by clinical staff, under the direction of a physician or other Qualified Healthcare Provider (QHP), or personally provided by a physician or QHP to a patient residing in a home, domiciliary, rest home or ALF (Patient must be in outpatient status)
• Services include:
• Establishing, implementing, revising or monitoring the care plan
• Coordinating the care of other professionals or agencies
• Educating the patient or caregiver about the patient’s condition, care plan or prognosis
• Physician or QHP provides or oversees the management and/or coordination of services, as needed, for *all* medical conditions, psychosocial needs, and activities of daily living.
• Includes typically non face to face services but may include direct face to face interventions.

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Pertinent AMA CPT Definitions

Clinical Staff

• A person who works under the supervision of a physician or qualified health care professional who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service

Physician or other QHP

• An individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports the professional service

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CPT Guidance Pertaining to Care Management Services

Care Management Activities

• Communication and engagement with patient, family, guardian, or caretaker, surrogate decision makers or other professionals
• Communication with home health agency
• Collection of health outcomes data
• Patient/family/caregiver education to support self-management
• Assessment and support for treatment regimen adherence and med management
• Identification of community and health resources
• Facilitating access to services
• Management of care transitions
• Ongoing review of patient status, including review of labs and studies not reported otherwise
• Development, communication and maintenance of comprehensive care plan

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Clinic/Practice Requirements

• Provide 24/7 access to physician or other QHP
• Provide continuity of care with designated member of care team who is available for f/u visits
• Provide timely access and management for follow up after an emergency department visit or facility discharge
• Utilize an EHR
• Utilize standard methodology for determining who require services
• Have internal care management processes to ensure patients identified as requiring care management services receive them in a timely fashion
• Use a standardized format in the medical record for documenting care management services
• Be able to engage and educate patients and caregivers as well as coordinate care among all service professionals, as appropriate.
• All team members providing services are clinically integrated

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Chronic Care Management Definition�(CPTs 99437, 99439, 99490-1)

Eligibility (Medical Necessity)

• Multiple chronic conditions (2 or more) expected to last at least 12 months, or until the death of the patient.
• Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation or functional decline

Service Content

• Medically necessary care management activities (previously defined) to address the qualifying conditions.
• Comprehensive care plan established, implemented, revised or monitored
• Staff time of at least 20 minutes in calendar month

Complex Chronic Care Management �(CPTs 99487 and 99489)

Eligibility (Medical Necessity)

• Multiple chronic conditions (2 or more) expected to last at least 12 months, or until the death of the patient.
• Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation or functional decline
• Meets organization defined criteria for eligibility for CCCM

Service Content

• Medically necessary care management activities (previously defined) to address the qualifying conditions.
• Comprehensive care plan established, implemented, revised or monitored
• Moderate or High Complexity Medical Decision Making
• Staff time of at least 60 minutes in calendar month

Principle Care Management�(CPTs 99424, 99425, 99426, and 99427)

Eligibility (Medical Necessity)

• A single high-risk disease, with following required elements
• The condition requires the development, monitoring, or revision of a disease-specific care plan
• The condition requires frequent adjustments in the medication regiment and/or the management of the condition is unusually complex due to comorbidities

Service Content

• Medically necessary care management activities (previously defined) to address the qualifying condition.
• Ongoing communication and care coordination between relevant practitioners furnishing care

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Coding CM CPT Codes

Coding Considerations

• The CM service period is one calendar month. Practitioners may report CCM at the conclusion of the service period, or after completion of the minimum required service time.
• CCM Service code(s) or category (CCM vs CCCM) may vary month to month depending on the patient’s medical needs.
• Only one provider may claim CCM services in a given month
• Precluded Services: Several CPT codes for other services may not be billed at the same time as CCM services (See next slide)
• Advanced Coding:
• Place of Service: Select to PoS code for where the patient would have been seen in person (Typically 11 – Office)
• NPI: The rendering provider is the provider supervising the care plan, not the staff who perform the service. In the case of Medicare, this will be the Medicare Provider and NOT the pharmacist

Chronic Care Management

Complex Chronic Care Management (CCCM)

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Principle Care Management

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Example Coding

Precluded Services� (can not be billed in a month with CCM, CCCM or PCM)

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Medicare Criteria for CCM and PCM

Medicare and CM Services

• CM Services are listed and priced on the Physician Fee Schedule (PFS)
• May be billed by enrolled Physicians and CNM, CNS, NP, or PA
• Services not directly provided by the billing practitioner and delivered by the practitioner’s clinical staff under their direction on an ‘incident-to’ basis under ‘general supervision.’
• General supervision means when the billing practitioner doesn’t personally provide the service, it’s done under their overall direction and control. We don’t require the physician to be physically present while the service is provided
• Incident-to basis means as an integral part of services provided by the billing practitioner
• Must be preceded by an E&M service or AWV service from the billing practitioner in the 12 months prior to starting CM service delivery.
• Copayment: Medicare 20% cost share applies.

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Medicare and CM Services Continued

• Patient Consent: Required verbal or written to be documented before the provision of any care management services. It does not need to be updated unless they switch to a different practitioner but many practices update annually.
• Must Include:
• The availability of CCM services
• Their possible cost sharing responsibilities
• That only 1 practitioner can provide and bill CCM services during a calendar month
• The patient’s right to stop CCM services at any time (effective at the end of the calendar month)
• That the practitioner explained the required information and whether the patient accepted or declined services

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Medicare and CM Services Continued

• Patient Records: An HER system acceptable under the HER Incentive Program must be used to document and record patient demographics, problems, medications and medication allergies.
• A Comprehensive Care Plan (when providing CCM and CCCM) must be established and:
• Must be maintained electronically.
• Must be person-centered, based on physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports
• Must be provided to patients and caregivers

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Medicare and CM Services Continued

• Access to care and care continuity should include:
• Providing 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified practitioners or clinical staff, including providing patients or caregivers with a way to contact their health care practitioners to discuss urgent needs no matter the day or time
• Providing continuity of care with a designated care team member with whom the patient can schedule routine appointments and who’s regularly in touch with the patient to help them manage their chronic conditions
• Providing patients and caregivers a way to communicate with their practitioners about their care by phone and through secure messaging, secure web, or other asynchronous non-face-to-face consultation methods (like email or a secure electronic patient portal)

Medicare Comprehensive Care Management Service Expectations

• Comprehensive care management should:
• Assess the patient’s medical, functional, and psychosocial needs
• Make sure the patient gets timely recommended preventive services
• Review medications and any potential interactions
• Oversee the patient’s medication self-management
• Coordinate care with home- and community-based clinical service providers
• Communicate with home- and community-based providers about the patient’s psychosocial needs and functional decline, and document it in the patient’s medical record
• Manage Care Transitions:
• Including referrals to other clinicians, or following up after an ED visit or after discharges from hospitals, skilled nursing facilities, or other health care facilities
• Creating and exchanging or sharing continuity of care documents promptly with other practitioners

Documentation Standards

Comprehensive Care Plan Content

Medicare

AMA CPT

Not limited to but may include:

• Problem list
• Expected outcomes and prognosis
• Measurable treatment goals
• Cognitive assessment
• Functional assessment
• Symptom management
• Planned interventions
• Medical management
• Environmental management
• Caregiver assessment
• Interaction and coordination with outside resources and other professionals
• Summary of advance directives

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Example Care Plan Template

Example Care Plan Template Continued

Documentation Format Examples

Pharmacist Role in CM

Care Management in Diabetes

Care Management in Diabetes

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• Requires a comprehensive and patient-centered approach aimed at optimizing glycemic control, reducing the risk of complications and enhancing the patient’s quality of life.
• Integrates medical, behavioral and lifestyle strategies
• Components:
• Glycemic targets
• Self monitoring plans
• Pharmacologic management plans
• Lifestyle interventions
• Screening for, prophylactic interventions for and management of complications
• Behavioral and mental health support
• Patient education and self management support
• Healthcare and technology literacy

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ADA Comprehensive Medical Evaluation and Assessment Recommendations

Glycemic Targets

Typical DM CCM Monthly Service

Non-Face to Face Patient Check In

• Frequency – Weekly to once monthly based on medical need
• Review and Assessment of:
• Patient Understanding of Care Plan
• Patient Self Efficacy
• Self Monitoring Records
• Medication Use and Management
• Lifestyle Intervention
• Education Needs
• Mood/Affect
• Signs or Symptoms of Complication or Progression
• Interventions as Appropriate
• Education
• Referral
• Recommendation or Order for laboratory screening
• Recommendation or adjustment of medication �(depends on facility privileging – at present this will be recommendation to provider unless otherwise documented)

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Care Coordination

• Review for care access services
• Does patient have access to all medications, supplies and recommended treatments?
• Does patient need prior authorization on a medication or service?
• Does patient need transportation assistance to access referral or specialty service?
• Review for due or overdue screenings and health maintenance interventions
• Immunizations
• Annual or routine screenings
• Lipid Panel
• CMP
• Urine Microalbumin
• A1c
• Foot Exam
• Annual referrals to external specialists
• Diabetic Retinal Exam
• Dental Examination
• Behavioral Health

For due/overdue screenings, lab tests or referrals already ordered, encourage completion and assist in connection to service when needed.

For due/overdue screenings, lab tests or referrals not yet ordered, document need and coordinate an order with PCP.

References

CMS.GOV CARE MANAGEMENT - LINK

MEDICARE LEARNING NETWORK BOOKLET – CHRONIC CARE MANAGEMENT – LINK

AMA CPT CODING MANUAL – 2024 EDITION

ADA STANDARDS OF MEDICAL CARE IN DIABETES 2024 - LINK

Discussion

Comments, Feedback or Questions?

Contact Us:

Zach Rosko: zacharyrosko@isu.edu

Jordin Millward: jordinmillward@isu.edu