When auditing Transitional Care Management (TCM) and Chronic Care Management (CCM) services, you may come into a situation where services are performed by clinical staff members. What constitute as a clinical staff member, and are they allowed to perform such services? What if they are not licensed?
CMS is vague about the definition of a clinical staff member and refers to CPT for guidance. According to the 2016 CPT Manual published by the American Medical Association, a clinical staff member is defined as "persons who work under the supervision of a physician or other qualified health care professions and 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." Additionally, TCM and CCM vary in their use of this terminology. CCM identifies these employees as clinical staff, while TCM uses the language licensed clinical staff.
Now that we have identified what a clinical staff member is, lets identify what TCM and CCM's requirements are for these individuals performing services. CCM allows clinical staff to perform services, even without a license as long as the supervising provider feels he/she is able to perform the service. However, if your state requires these certain services to be performed by a licensed individual, then he/she must be licensed. In this scenario where the individual is not licensed, the service would be provided incident-to.
TCM's requirements are a little different. While they allow unlicensed clinical staff to perform part of the service, they require that he/she must follow incident-to guidelines (i.e. his/her provider must be onsite, no new services, etc.). If they are licensed, the incident-to guidelines do not need to be met.
As auditors, it is our duty to ensure that services are properly billed, so being aware of requirements like these is imperative to ensuring our precision as auditors. Don't forget that NAMAS offers additional resources to help you navigate the world of auditing. Through our online forum, you can post your questions for a response from our team, or respond to questions posted by your peers. If you are a current member, use our Ask an Auditor feature within your members only area to pose your question to the NAMAS team. Our main goal has always been to be THE resource for training and education for auditors.
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