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Chronic Care Management – It’s Time to Bill!

In 2015, the Centers for Medicare & Medicaid Services (CMS) begins payment for the new CPT® code, 99490. This code can be used for non-face-to-face chronic care management (CCM) services, without restriction on specialty. Given the multitude of work that you provide outside of the exam room to care for your patients, this new code represents an important opportunity for getting paid what you deserve.

The American Medical Association (AMA) describes 99490 as follows:

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

  • Multiple (two or more) chronic continuous or episodic health conditions that are expected to last at least 12 months, or until the death of the patient.
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. 
  • Comprehensive care plan established, implemented, revised or monitored.

The code is reported when, during the calendar month, at least 20 minutes of clinical staff time is spent in care management activities. There is no list of the chronic or episodic health conditions; that definition is left up to your determination accounting for the additional guidance provided in the description of the code. Face-to-face services may also be billed (and paid) during the month, but the AMA lists approximately 40 CPT codes involving care management that can’t be used during the same month, including ESRD services.

Only one physician can bill and receive payment for 99490 for providing the service to a Medicare patient, with payment at a rate of approximately $42.91. The “spirit” of the code is that it is the physician who is actively managing the patient’s comprehensive plan of care - physical, mental, cognitive, social, functional and environmental.  (Because Medicare payment varies slightly based on geography, your reimbursement may be a few dollars better – or worse – than the national average.) While $42.91 may not sound like a lot, consider that’s $515 per patient per year. With just 25 patients under active care, receiving services each month, that equals $12,873 in new revenue! Note, however, that the months do not need to be consecutive, nor does the time involved in CCM.

For Medicare patients, CMS makes special note that the services may be provided under general supervision, which does not require the presence of the physician. Neither the AMA or CMS have outlined the definition of “clinical staff,” but no licensure or certification is required according to the material thus far released from these organizations. However, you must have an electronic health record (EHR) in order to bill the code for Medicare patients – a first for CMS. A newly certified EHR isn’t necessary, however; physicians can use whatever certified EHR version (2011 or 2014) you had on December 31, 2014 in order to bill in 2015. Furthermore, CMS requires the following:

  • Provision of 24/7 access to address the patient’s acute chronic care needs;
  • Continuity of care with a provider with whom the patient is able to obtain “successive routine appointments;”
  • Systematic assessment of the patient’s medical, functional and psychosocial needs;
  • The creation of a documented, patient-centered care plan;
  • An electronic care plan that is accessible at all times;
  • Care transition management; and
  • The ability to communicate with the patient and caregiver through secure messaging or other asynchronous communication methods, not just the telephone.

In the Final Rule, CMS revealed that 99490 will be subject to cost-sharing. Because of this, CMS announced:  “…we are requiring that providers explain to beneficiaries the cost-sharing obligation involved in receiving CCM services and obtain their consent prior to furnishing the service.” Thus, you’ll need to develop a consent form for patients to complete, and keep a signed copy in the patient’s record. According to CMS, the document must include informing the patient of his or her right to discontinue the CCM services at any time, the consequences of doing so, an authorization to communicate with other treating providers, and the fact that only one physician can furnish and be paid for the services. CMS revealed that it has no intention of issuing a model consent form, so it’s up to you to develop one.

CMS had not yet released a memorandum regarding 99490, but my recommendation for billing purposes is to use field 24a (date of service) on the CMS1500 form to enter the month in which the service was rendered. Record the first day of the calendar month in the “from” field, and the last day of the month in the “to” field, completing the boxes in a six-digit format (e.g., MMDDYY). Note that you normally place the date of service in the “From” field only, but you’ll need to use both fields in 24a when billing the 99490 to indicate the range for the month.  See this link for instructions from CMS regarding the CMS1500 form. Use the appropriate two-digit place of service code for the location where you provided the services (e.g., 11 for “Office”).

You can read more about CMS’ reimbursement policy on pages 67716 through 67730 in the Final Rule. Register for the CMS webinar on February 18, 2015.

In the meantime, consider what may be the biggest stumbling block of all – how to account for time across the month. Sure, you may be able to record the time of one transaction (for example, one phone call with the patient’s spouse about your recommendations for the plan of care), but summing up the time across the month may prove to be more difficult. Discuss the situation with your EHR vendor; if necessary, look for a integrated or “bolt-on” solution for care management that includes the tracking of time. If an electronic tracking mechanism isn’t possible or you need an interim solution, opt for a manual one instead. First, run a report from your practice management system querying all of the active patients who have two or more chronic illnesses using ICD-9 codes. The parameters may be 12, 18 or 24 months, depending on how actively the patients are being managed. Review that list with your clinical team, and extract all of the patients for whom you have – or will – establish a “comprehensive care plan.” Create a CCM spreadsheet, and sort the patients by last name in alphabetical order. Incorporate a marker for the consent (so as to ensure that a signed consent is on file). Put the dates of the month across the top, with each tab of the spreadsheet serving as a month. Save the spreadsheet on a shared drive. Instruct your clinical team to access the spreadsheet when they render any chronic care management-related activity, search and find the patient’s name, and record the minutes of the activity in the cell below the specific date. At the end of the month, sum the time to see if any met or exceeded 20 minutes, and – voila – you’ll have your list of patients to bill!

Remember that this spreadsheet can’t (and shouldn’t) be your only documentation. The documentation of the activity should be in the patient’s record, accompanied by an accounting of the time. Your CCM spreadsheet is really just a redundant system to allow you to easily and comprehensively ensure that you are capturing all patients for whom CCM billing is possible. Of course, opt for an automated solution if you have access to one!

Woodcock & Associates: Changing the Way You Work