Physician practices can now receive payment for non-face-to-face care coordination services provided to Medicare patients with multiple chronic conditions. Chronic care management (CCM) services (CPT code 99490) must entail at least 20 minutes of clinical staff time per calendar month, directed by a physician or other qualified health care professional, for a patient with multiple chronic conditions expected to last at least 12 months or until death. To help physicians determine whether they can bill for CCM, please see the following frequently asked questions.
What conditions are considered chronic?
A patient must have two or more chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Such conditions are, but not limited to: Alzheimer’s disease and related dementia, asthma, cancer, depression, diabetes, ischemic heart disease, and osteoporosis.
What service must a practice furnish prior to providing or billing for CCM?
A practice must furnish an annual wellness visit, initial preventive physician exam, or a comprehensive evaluation and management visit billed separately.
Must a practice obtain consent from the patient before furnishing and billing for CPT code 99490?
Yes. A practice must obtain a written agreement to have CCM services provided, including authorization for electronic communication of medical information with other treating physicians or providers. An explanation of the CCM services and whether the patient gave consent should be noted in the patient’s medical record. The patient also should be informed:
Who can bill for these services?
Only one practitioner can bill per month. CCM may be billed by a primary care physician, specialty physician who meets all of the billing requirements, or non-physician practitioners (nurse practitioners, physician assistants, clinical nurse specialists, and clinical nurse midwives).
Does the beneficiary consent require yearly renewal?
No. A renewal is only required if the patient changes primary care physicians.
What is the Medicare payment rate?
Approximately $43.00 (office) per beneficiary per month. Standard coinsurance applies.
How do Medicare’s “incident-to” rules apply to CCM?
Clinical staff can provide CCM services incident to the services of the billing physician when under the general supervision of the physician (or other appropriate practitioner).
What services do I need to provide to be paid for Chronic Care Management?
Create a structured clinical summary of the beneficiary’s demographics, health and medical information using a certified Electronic Health Record.
Provide access to care management services 24/7 either through a patient portal, monitored secured email, etc.
Take time to access the beneficiary’s medical, functional, and psychosocial needs and ensure that preventive care services are delivered on the appropriate time schedule.
Review medications and help the patient manage their own medications.
Provide a plan unique to the beneficiary that addresses all health issues. Include physical, mental, cognitive, psychosocial, functional and environmental (re)assessments. Share plan as appropriate with other practitioners and providers. Electronically capture care plan information and make available on a 24/7 basis to all practitioners within the practice whose time counts toward the time requirement for the practice to bill for CCM.
Provide the beneficiary with a written or electronic copy of the care plan and document that you provided the information the beneficiary’s electronic medical record.
Designate a practitioner or member of the care team to provide continuity of care.
Manage care transitions including referrals to other providers; follow-ups after Emergency Room visit, hospital discharges, or other health care facilities.
Coordinate with home and community-based clinical service providers.
Provide multiple ways for the beneficiary to communicate with practitioners (phone, secure messaging, Internet, etc.).
Is charting time completed by a nurse within the physician’s practice counted toward CCM clinical staff time?
Yes. Chart documentation related to the CCM services is counted as part of required the 20 minutes of clinical staff time.
Will CMS allow provider-based physicians to report the CCM services?
If the service is provided in an institutional setting, i.e. hospital or skilled nursing facility, then the provider-based physicians cannot bill for CCM services in order to avoid an overlap in payment with the hospital or facility.
If a pharmacist is in the employ of a physician’s practice, can the pharmacist’s time be counted toward the clinical staff time?
Yes, provided the work is related to the CCM service and within the scope of practice for pharmacists, such as medication management.
If an on-call physician who is not part of the group practice has access to the patient’s medical records, does that meet the definition of 24/7 access?
If the physician has a contractual arrangement and it falls within the incident-to rules, then that would be acceptable for 24/7 access.
Can transitional care management services (CPT codes 99495-99496) be billed in the same month as CCM?
No. Transitional care management services and other overlapping care management services cannot be billed during the same month as CCM. HCPCS codes G0181/G0182 (home health supervision/hospice care supervision) and CPT codes 90951-90970 (End stage renal disease services) also cannot be billed during the same service period.