Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Billing for Chronic Care Management Services

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New for 2015, Medicare now reimburses physicians for managing chronic care for their beneficiaries. Separate payment of about $43 for this service will be provided through the Medicare Physician Fee Schedule using CPT code 99490 for non face-to-face care management/coordination. The beneficiary’s standard coinsurance applies.

In order to bill for the service, beneficiaries whose care is being managed must be diagnosed with two or more chronic conditions that are expected to last at least 12 months or until the death of the patient and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. The service can be billed once per calendar month if eligible providers furnish a minimum of 20 minutes of qualifying care. Only one practitioner can bill per month (per CPT and Medicare instructions), and Transitional Care Management (TCM) and other overlapping care management services cannot be billed during the same service period.

Physicians, Certified Nurse Midwives (CNMs), Clinical Nurse Specialists (CNSs), Nurse Practitioners (NPs), and Physician Assistants (PAs) can furnish Chronic Care Management (CCM), including the use of general supervision of other clinical staff as part of an “incident to” circumstance. Typically, CCM would be furnished by a primary care practitioner, but specialists can bill CCM if all requirements are met. Services provided directly by a physician or non-physician practitioner, or by clinical staff incident to the billing physician or non-physician practitioner, count toward the minimum amount of service time required to bill the CCM service. While non-clinical staff time may be required to bill CCM, it cannot be counted toward the minimum of 20 minutes per calendar month.

CCM Services have several requirements outlined generally below; to bill for chronic care management, the practitioner must do the following:

Obtain Patient Permission

  • obtain and document the beneficiary’s informed consent for the service, including permission to electronically share relevant medical information with other providers. Beneficiaries must also be informed that they have the right to discontinue CCM, verbally or in writing, at any time (effective at the end of the service period) and the effect of revoking the agreement, that only one practitioner can furnish and be paid by Medicare for CCM within a service period, that cost sharing is involved, and that the billing practitioner must initiate the CCM service prior to furnishing or billing it, during a face-to-face visit.

Collect Data

  • make a structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record, using a certified EHR.

Develop a Care Plan

  • maintain an electronic care plan for all health issues that is patient-centered, based on a physical, mental, cognitive, psychosocial, functional, and environmental assessment or reassessment, etc. that is available 24/7 to all practitioners within the practice whose time counts towards the time requirement for the practice to bill the CCM code.
  • share care plan information electronically (other than by fax) as appropriate with other providers and practitioners, as well as written or electronically to the patient/caregiver.

Maintain Patient Access

  • provide patients with 24/7 access to care management services.
  • ensure continuity of care between the patient and a designated member of the care team, including the ability to obtain successive routine appointments with this individual.
  • provide for enhanced communication opportunities between the patient and caregiver through telephone, secure messaging, secure internet, or other asynchronous non face-to-face consultation methods (subject to HIPAA).

Manage Care

  • make a systematic assessment of health needs and receipt of preventive services; medical, functional and psychosocial needs; and medication, including a review of adherence and potential interactions and oversight of patient self-management of medications.
  • manage transitions between and among health care providers and settings including referrals to other clinicians, follow up after ER visits, and follow-up after discharges from a hospital, skilled nursing facility, or other health care facility and create/format clinical summaries according to CCM certified technology.
  • coordinate with home and community-based clinical service providers as appropriate.

The Centers for Medicare and Medicaid Services requires the use of certified EHR technology to satisfy some of the CCM scope of service elements. In furnishing these aspects of the CCM service, CMS requires the use of a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31st of the calendar year preceding each Medicare PFS payment year (referred to as “CCM certified technology”).

For more information about billing Chronic Care Management, review the CMS Chronic Care Managements Services Fact Sheet or the slides from a recent MLN Connects National Provider Call on Chronic Care Management Services.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com. Photo by David Wall via Flickr used with permission under the Creative Commons License.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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