In 2015, the new code 99490 was announced in Medicare to cater to patients with more than one chronic disease. It was a huge win because the role involved a lot of services that were previously deemed as unbillable time. Here is everything you need to know about how to bill chronic care management 99490 to Medicare.
What is Chronic Care Management
Chronic care management refers to the continuity of treatment received for patients with numerous chronic conditions outside of the daily office visit. By 2015, Medicare began providing refunds monthly for these forms of services. Non-complex CCM services, billed under CPT 99490, cover at least 20 minutes of clinical staff time per calendar month. They’re managed by a physician or other trained healthcare professional, and provide the following services:
- Better communication opportunities
- Integral Care Planning
- Usage of accredited EHR technology (needed for billing CCM codes, but no longer necessary for CCM documentation or transitional care documentation)
- 24/7 Care continuity & access
- Managing Transitions in Treatment
- Comprehensive treatment management
- Coordination of treatment at home and in the Community
It’s important to know that an initial visit is a requirement for new patients or patients that have not been seen in the past year. There could be an Annual Wellness Assessment, First Preventive Physical Exam, or another face-to-face meeting with the billing practitioner. Such a visit does not form part of the CCM program and is billed separately. Billing practitioners must also get consent from the patient before offering CCM services or billing for it.
Complex CCM services, billed in compliance with CPT 99487, will also require significant revision of the treatment plan, moderate or high difficulty medical decision-making, and at least 60 minutes of clinical staff time every calendar month. They must be directed by a physician or other trained health care professional.
Patient Eligibility
CCM services are allowed for patients with more than one chronic condition expected to last a minimum of 12 months or till the patient dies. The illness must also put the patient at serious risk of mortality, acute exacerbation/decompensation, or functional decline.
Billing practitioners may recommend defining patients needing CCM services using the criteria provided in the CPT guidelines (such as number of diseases, number of prescriptions, and repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language.
Racial, ethnic, and geographical inequalities in health need to be reduced by the provision of CCM services.
The billing practitioner cannot disclose both complex and normal (non-complex) CCM services for a patient in the same month. In other words, within a given service time, a given patient receives either complex or non-complex CCM and not both. Do not assign 99491 to 99487, 99489, or 99490 in the same calendar month.
Some types of chronic medical conditions are:
- Arthritis (rheumatoid and osteoarthritis)
- Asthma
- Autism spectrum disorders
- Atrial fibrillation
- Cardiovascular disease
- Alzheimer's disease and associated dementia
- Cancer
- Chronic obstructive lung disease
- Diabetes
- Depression
- Infectious diseases like HIV / AIDS
- Hypertension
Practitioner Eligibility
The following groups of practitioners can bill for CCM:
Physicians
Non-Physicians
- Clinical Nurse Specialists
- Certified Nurse-Midwives
- Nurse Practitioners
- Physician Assistants
Other clinical staff may provide the CCM service when operating under the general supervision of an eligible physician. CCM programs can also be paid through Rural Health Clinics, Critical Access Hospitals, and Health Centers with federal qualifications. If two practitioners give a patient CCM in the same practice, only one will bill for the code in any given month.
Primary care practitioners may most often bill CCM. Specialist practitioners can also provide and bill for CCM services under some circumstances. The CCM service is not within the practice scope of some limited-license practitioners and physicians, such as dentists and clinical psychologists. These practitioners may collaborate or refer to these physicians to organize and manage treatment.
CPT codes 99487, 99489, and 99490 include time spent by the clinical staff or billing professional, and it counts against the average time the clinical staff needs to spend in a given month. CCM services not rendered directly by the billing practitioner are delivered on an “incident-to” basis by clinical personnel under the billing practitioner (as an integral part of the services offered by the billing practitioner), subject to relevant state legislation, licensing, and practice scope. The clinical workers are either employees or contractually hired by the billing agent that collects payment directly from Medicare for CCM.
Initiating Visit
Medicare needs initiation of CCM services during a face-to-face visit with the billing practitioner called an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or another face-to-face visit with the billing practitioner.
The Annual Wellness Visit usually applies to new patients or patients not seen within one year before the start of CCM. This initiating visit does not form part of the CCM program and is billed separately.
Practitioners who make an initiating visit to the CCM and personally carry out extensive evaluations as well as CCM care planning beyond the normal effort listed in the initiating visit code may also bill HCPCS code G0506. G0506 represents comprehensive evaluation and care planning by a physician or other trained healthcare professional for patients needing chronic care services. Following initiation of the CCM, G0506 is reportable once per CCM billing practitioner.
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Patient Agreement and Consent
Having advanced consent for CCM services means that the patient is involved and aware of the available cost-sharing. This can also help to avoid duplicative billing by practitioners. Until furnishing or billing CCM, a practitioner must get approval from the patient. Consent can be written or verbal but must be stated in the medical record. The patient must know the following:
- Availability of CCM services and cost-sharing opportunities applicable
- Only one provider can provide and be paid for CCM services during a calendar month
- Right to cancel CCM services at any time (effective at the end of the calendar month)
- Authorization should also be obtained for the electronic transmission of medical knowledge.
The aim here is to have everything in the patient’s medical record clearly stated, and preferably, within the patient agreement. Revocations, consents, and any modifications in the CCM service must be recorded.
Informed consent for patients only needs to be received once before CCM is activated, or if the patient wants another health practitioner to supply and charge CCM.
While cost-sharing for patients applies to the CCM program, most patients have extra insurance to help fund cost-sharing for the CCM.
CCM can also help to prevent the need for more costly care in the future by proactively monitoring patient safety, rather than simply treating serious or acute illness and disease.
Steps in Billing CCM 99490
1. Identify Eligible Clients
You can use the Electronic Health Record to check for patients with more than two chronic conditions and run through reports sorted by the physician. Every practice will then review the report and exclude people who are not a good match for the CCM program
The patient must have two or more chronic conditions and also the following important elements:
- Chronic conditions intended to last for 12 months or until death.
- Conditions that put the patient at serious risk of death, acute exacerbation/decompensation, or decrease in function.
You should concentrate on a small number of different diseases, such as COPD, diabetes, CVD, and A-fib when you start introducing a CCM service.
Contact the patient with an outreach initiative or address the CCM program during a regularly scheduled visit to encourage knowledge and understanding of the importance of chronic disease management. A good example is a dedicated telephone line that links to personnel with specialized CCM expertise. After hours this line is forwarded to the on-call clinician.
2. Inform and Enroll
Educate patients and allow them to participate in using a letter of invitation, accompanied by written consent. Explain the program interest, how the program operates, and the fact that it can be rejected, postponed or terminated. Also include details on how to terminate and transfer the service.
Authorization to share medical information electronically with other physicians depends on local and state regulations. Give details on the names of the appointed physician and the name of the CCM nurse.
Also, explain the monthly scheduled nurse appraisal appointment, which should be viewed as a routine visit, even though it occurs by telephone. Explain how and when bills are produced and the patient’s responsibility for coinsurance payments and deductibles.
It’s important to also check and verify the patient’s participation agreement by obtaining their signature on the consent form. Report it in the electronic chart that CCM has been clarified. You have obtained written consent to approve or refuse services from which (name of clinician) the electronic care plan is provided, and the right to stop CCM services at any time.
3. Interact with Them and Activate the Service
To provide care management for chronic conditions, you need to:
- Provide a comprehensive evaluation of the patient's medical, functional, and psychosocial needs.
- Ensure that all appropriate preventive care services are provided on time.
- Share the full treatment plan with other physicians and providers as necessary.
Provide patients with a written or online copy of their detailed treatment plan. It is a low-cost way to send the care plan to the patient portal, thereby allowing all eligible patients (or their designated caregiver) to participate and become familiar with portal use.
Record the amount of time spent.
It’s possible to set up a program that will keep track of time spent on non-face-to-face services, including:
- Phone calls and email contact with patients.
- Arranging treatment with other doctors, hospitals, community resources, and caregivers (via the internet or other electronic correspondence)
- All medication reconciliation and prescription management
4. Bill for Rendered Services and Get Your Reimbursements.
Validate that the criteria were met every month for each patient. You should also ensure that all the necessary conditions have been met before you submit CCM billing under CPT code 99490 at the appropriate time.
FAQs
No, you can only furnish one form of CCM per service period. CPT reporting rules apply where CPT code 99491 can’t be reported with CPT codes 99487, 99489, or 99490 for the same calendar month.
Perhaps. The place of residence can be an assisted place of living or nursing home. You will need to find out how to sign the patient. If the facility accepts Part A, then you will not be able to bill CCM services. Instead, you should use codes such as 99307, 99308, and other certification codes for home health.
Practitioners can review the CPT definition of the word “clinical staff.” However, clinical staff’s time should only be considered if the requirements of Medicare, such as supervision, relevant State law, licensing, and practice scope are met.
Other staff can also help to promote CCM services, but only time spent by clinical personnel can be counted. Where the billing practitioner provides CCM services themself, the billing practitioner’s time can be counted as clinical staff time or added to professional CCM reporting.
At the very least, give them what Medicare requires. The only instance where they might not pay is if they’re a capitated Advantage plan. However, some Advantage programs do give and go beyond Medicare’s minimum standards.
No. For the codes, the time should be considered the standard times for office visits for evaluation and management purposes. These are presumed times defined by the American Medical Association through a physician survey. The codes were developed and valued for how much time the billing practitioner spends on themselves every month, but are not specific times. Time for the billing practitioner may go into tasks such as managing clinical personnel, conducting clinical staff operations personally, or, in the case of complex CCM, undertaking professional decision-making with moderate to high complexity.
All the variety of service elements should be regularly delivered in a given service span, except a specific service is not required or medically suggested. An instance is when the recipient does not have hospital admissions that month, so there is no management of a hospital discharge transition. All parts and the descriptors of the CPT code must be furnished for billing.
Standard CCM referring to CPT code 99490 assumes up to 15 minutes of work by the billing practitioner, and this portion of the service rendered cannot be delegated to another contractor. All the CCM service codes are expected to include the billing practitioner’s ongoing monitoring, supervision, collaboration, and reassessment aligned with the required service elements. The billing practitioner cannot assign or subcontract this work to any other person.
The duration of service to the CCM claim is one calendar month. Practitioners can report CCM when the service period is over or after the minimum required service time has been completed.
Yes. CCM is priced in the facility and non-facility settings under the PFS. The POS on the claim application should be in the location where the billing professional will normally give the recipient a face-to-face treatment.
No. As provided for in the calendar year (CY) 2014 PFS final rule with consultation period (78 FR 74424), a new consent is only required if the patient switches billing practitioners. In that scenario, the new billing practitioner must obtain and record a new consent before the delivery of the service.
When the beneficiary dies during the service cycle, the CCM service code(s) will be billed as long as the necessary service time for the code(s) has been met for that calendar month. Also, all other billing conditions must be met.
Conclusion
With this guide, you should have a more in-depth understanding of the intricacies involved in chronic care management and billing to Medicare. You also have enough resources to guide you through the steps of billing CCM 99490. Be sure to check insurance companies and your local Medicare carrier for any unique billing policies you need to know about.
