Uncertainty about how to comply with the established patient requirement is throwing a wrench in plans to provide chronic care management (CCM) services. Although CCM is in the enviable position of CMS wanting to increase its utilization, questions about the established patient and other requirements are discouraging some providers, an expert said.

CCM services are nontraditional office visits for people with multiple chronic conditions, said Martie Ross, a consulting principal at PYA. They’re provided in physician practices or hospital outpatient departments by clinical staff and/or physicians and nonphysician practitioners (NPPs), depending on the code. “The term we use is fee-for-service population health,” Ross said. “It’s a way to build the infrastructure you need to manage value-based contracts but still get paid on a fee-for-service basis.”

But there are compliance hiccups and she’s waiting for CMS to address them. A biggie is the established patient rule, which requires physicians to have an initiating visit with patients before embarking on CCM. It must be a comprehensive evaluation and management, transitional care or annual wellness visit, with a discussion about CCM. “Additional time spent assessing the patient and developing the care plan may be reimbursed under an add-on code for the initiating visit” (HCPCS G0506), she said Oct. 11 at a PYA webinar.

There’s an exception to the initiating visit requirement for patients who have seen the physician in the past year (i.e., is an established patient). That’s where compliance gets tricky. What if the only way to affordably provide CCM is to partner with a CCM company? The company’s physician conceivably could perform the initiating visit even though the physician has no ongoing treatment relationship with the patient and it may not otherwise be medically necessary, Ross said. That means the visit is billed under the national provider identifier (NPI) of a different physician than the practice that provides ongoing care for the patient. There are also compliance questions around physician supervision when CCM companies are involved.

There’s tension sometimes between the chief innovation officer, who wants to stand up the program, and compliance, which wants to be cautious, Ross said. “People have to decide the level of risk they’re willing to bear. Part of the equation in that risk analysis is CMS is actively encouraging providers to furnish these services.”