Documentation requirements for chronic care management services

On August 9, the Office of Inspector General (OIG) published a review of whether Centers for Medicare and Medicaid Services (CMS) payments to providers for noncomplex and complex chronic care management (CCM) services during calendar years 2017 and 2018 complied with federal requirements. Of the over 8 million claims reviewed by the OIG, 50,192 claims did not comply with federal requirements, resulting in just over $1.9 million in overpayments and $540,680 in beneficiary cost-sharing. Most issues (38,447 claims) were found in instances where providers billed noncomplex or complex CCM services more than once for the same beneficiary in the same service period. Other issues included instances (10,882 claims) when the same provider billed for both noncomplex or complex CCM services and overlapping care management services rendered to the same beneficiary in the same service period, as well as instances (863 claims) in which incremental complex CCM services were billed along with complex CCM services identified as overpayments. The OIG said these errors occurred because CMS did not have claim system edits to prevent and detect overpayments. 

The OIG recommends CMS direct the contractors to recover the $1.9 million for claims within the reopening period and refund up to $540,680 in cost-sharing that beneficiaries were required to pay. It also recommends CMS implement claim system edits to prevent and detect overpayments for these services and notify providers so they can identify, report, and return any overpayments in accordance with the 60-day rule. CMS concurred with the recommendations but raised concern about whether providers are liable for the overpayments because they may be found to be without fault under the Social Security Act. View a full report on the this information.

Chronic Care Management Services are provided to patients with at least two chronic conditions placing the patient at significant risk of death, acute exacerbation or functional decline.

Chronic Care Management consists of non-complex and complex codes which are identified at the Centers for Medicare and Medicaid Services. 

To bill for Chronic Care Management the following information must be documented in the patient’s medical record:

• Patient consent
• Comprehensive care plan
• Multiple (two or more) chronic conditions 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 
• Comprehensive care plan established, implemented, revised, or monitored assumes 15 minutes of work by the billing practitioner per month

If you have any additional questions, please contact Salma Tahir 646-895-4038 or Claire Niles 860-271-4832 in the Office of Privacy and Corporate Compliance (OPCC).