Care Coordination Billing Faces Audit Risk
As practices expand care coordination services (CCM, PCM) to generate new revenue, they face growing audit risks. Billing consultant blueBriX warns that without proper strategies to prevent revenue leakage and ensure compliance, providers could face significant financial penalties.
The Department of Health and Human Services' Office of Inspector General (OIG) is intensifying its scrutiny of care coordination services, driven by data showing significant billing errors. In one audit covering 2017 and 2018, the OIG identified $1.9 million in overpayments for Chronic Care Management (CCM) services due to improper billing. The most common reasons for these overpayments were not complex fraud schemes but procedural failures. Duplicate billing—charging for CCM more than once for the same patient in the same month—accounted for $1.4 million in improper payments in an OIG review. Billing for overlapping services, where providers billed for both CCM and other care management programs in the same period, was another major contributor. The Department of Justice (DOJ) has recently made CCM compliance an enforcement priority, signaling a new level of legal and financial risk for providers. This increased focus is a direct response to the rapid growth in non-face-to-face services, which are now seen as a high-risk area for potential waste and abuse. CMS first introduced billing codes for CCM in 2015 to pay for the critical, non-face-to-face work of managing patients with multiple chronic illnesses. The goal was to improve care coordination and reduce overall healthcare costs for high-risk populations. However, billing accuracy remains a significant challenge. In 2023, an analysis found that 18% of billed CCM services were for patients with only one chronic condition recorded on the claim, and 5% had none, despite the program requiring two or more. This type of data signals to auditors that foundational eligibility requirements are not being consistently met. Claim denial rates for CCM services hover between 25-30%, primarily due to failures in documenting patient consent, maintaining a comprehensive care plan, and accurately tracking time. These issues represent direct revenue leakage and are key red flags that can trigger a deeper audit. Auditors are specifically targeting documentation that fails to prove medical necessity and the required complexity for certain codes. For instance, billing for complex CCM (CPT 99487) requires demonstrating moderate-to-high complexity medical decision-making, not just meeting the 60-minute time threshold. The OIG has explicitly recommended that Medicare contractors recover identified overpayments and has urged CMS to implement better system edits to prevent improper billing in the first place. This indicates a shift from retroactive audits to more proactive claims analysis and enforcement.
