CMS has published the Medicare Physician Fee Schedule Final Rule for 2014.  One of the modifications adopted by CMS is the implementation of a separate payment for chronic care management services under the Physician Fee Schedule starting in calendar year 2015.  The separate payment will be made for chronic care management services furnished to patients with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

Chronic Care management services will include the following:

• The provision of 24-hour- a-day, 7-day- a-week access to address a patient’s acute chronic care needs.

• Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.

• Care management for chronic conditions including systematic assessment of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications. The practitioner furnishing chronic care management services must create a patient-centered plan of care document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care will typically include, but will not be limited to, the following elements: problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identification of  the individuals responsible for each intervention, requirements for periodic review and, when applicable, revision, of the care plan.

• Management of care transitions within health care, including referrals to other clinicians, visits following a patient visit to an emergency department, and visits following discharges from hospitals and skilled nursing facilities. The practice must be able to facilitate communication of relevant patient information through electronic exchange of a summary care record with other health care providers regarding these transitions. The practice must also have qualified personnel who are available to deliver transitional care services to a patient in a timely way so as to reduce the need for repeat visits to emergency departments and re-admissions to hospitals and skilled nursing facilities.

• Coordination with home and community based clinical service providers required to support a patient’s psychosocial needs and functional deficits, with communication to and from home and community based providers documented in the practice’s medical record system.

• Enhanced opportunities for a patient and caregiver to communicate with the provider regarding the patient’s care through not only the telephone but also through the use of secure messaging, internet or other non face-to-face consultation methods.

The addition of a payment category for chronic care management services evidences a recognition on the part of CMS that physicians and other clinicians are spending a significant amount of time providing care coordination services that are not adequately compensated under existing evaluation and management codes.  It is also evidence of the continued focus by CMS on the furtherance of the patient-centered medical home model, the reduction of hospital re-admissions and an increased reliance on technology and non-face to face methods to coordinate the delivery of care.