Saturday, February 7, 2015

99490: Chronic Care Management Services

Here's the latest that I've been working on...  Documentation for the new code 99490 Chronic Care management...  It sure feels like this is going to be one of those codes that opens up more questions than we have answers for...  Happy Coding 

As of January 1, 2015 CPT added code 99490, Chronic Care Management Services.  This code can be found in the 2015 CPT book in the E&M section under the Care Management Services subsection.  This new code is designated for management of chronic disease.  This code has some specific guidelines to be followed and they are carefully outlined in the CPT book.  However, it seems that this new code has also raised questions regarding appropriate use, and how to track, manage, and get reimbursed for it.

CMS (Center for Medicare and Medicaid Services) has designated code 99490this as a time based code, but have also included additional criteria that must be met prior to a claim being submitted for payment.  According to the CMS Physician Fee Schedule for 2015 the national average for this code, payment can be up to $46.87 (see below).  Private 3rd party insurance payers may reimburse at a different rate, and that would need to be disclosed by them via your contracted rates, and or published private fee schedules.  The CMS web site where you can find your specific locality for reimbursement for your Medicare/Medicaid claims is at
Chronic care mgmt service 20 min  

The fact that CMS has given their stamp of approval on this code is a huge move forward in the overall care of a chronically ill patient.  This bodes well for overall patient care, and care management of chronic disease.  This code would also be billable for patients covered with 3rd party private insurance, and not just for the Medicare and Medicaid population demographic. 

The issue that has been the most controversial in regard to the 99490 CCM (Chronic Care Management) code is how to manage and track the delivery of this care. Chronic Care Management Services provided to a patient can be face to face or non-face to face, and may include the establishing, implementing, revising or monitoring the current care plan, the coordination of care that involves other professionals and/or agencies and the most important is this “plan of care” needs to be documented and shared with the patient and/or current caregiver(s) of the patient. 

In the description of code 99490 noted in the CPT book CCM Services state that this code provide “at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month and requires these elements….”  In addition CPT also states that these criteria must also met:

¨     Multiples (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;

¨     The chronic conditions place the patient at significant risk of death, acute exacerbation/de-compensation or functional decline;

¨     Comprehensive care plan has been established, implemented revised or monitored.

Documentation and Medical Necessity

Good clear documentation of the patient and the medical necessity must be clearly established within the patient record before the coder/bilker can submit a claim for payment.  However this documentation requirement needs to be clearly noted in the patient record, in addition to the amount of time spent in performing this “Chronic Care” management.  This management of care does not have to be performed by the physician or mid-level themselves, this management can be performed by any clinical staff member, however it has to be under the direction of the physician or mid-level, which means the orders, and implementation need to be clearly documented. 

The time requirement must be at least 20 minutes spent within a calendar month, however, if more than 20 minutes are spent, there is not any additional monetary compensation to the provider.  Other E&M services that are provided during this calendar month can be billed, however must be separately identifiable from the Chronic Care Management Services. 

CPT has also included numerous bulleted guidelines for the Care Management Services section.  These guidelines must also be adhered to in addition to the ones provided under the Chronic Care Management Services section.  In these bulleted guidelines CPT has denoted that there must be a utilization of an electronic health record system, and that there be a standardized for and/or format in this medical record for the practice.  This may be a problem if the current practice is still on a hard-copy medical record system. 

Clinical documentation of the patients’ chronic diseases that are being managed then billed under the code 99490 need to be clearly outlined to reflect that they will last at least 12 months, and the clear notation to place the patient at significant risk of acute exacerbation/de-compensation or functional decline.  This verbiage is somewhat vague as to what represents “significant risk”.  A coder/biller will need to have a clear understanding from the provider and good documentation within the record to be confident in billing this service code.  The addition of the time-factor of 20 minutes or more will also need to be clearly evident. This could be done as “time in/time out”  or a notation comprising the total amount of time spent on CCM on a specific date.  It would be optimal if the electronic medical record can incorporate both the time and medical necessity within the software so this can be easily tracked and billed.

Beneficiary Notices and billing of the 99490 on a claim

For Medicare/Medicaid beneficiaries, the 2015 CMS final rule for reimbursement on code 99490, they require documentation that the patient has been informed and  acknowledges the following:

¨     Informed upfront and acknowledge that they are willingly participating in the CCM program, (e.g. sign an ABN prior to  billing)

¨     Informed that they can “opt-out” of this program at any time. 

¨     Informed and understand that these services provided can take place face to face, or non-face to face,

¨     Informed and understand that they, as the patient, are responsible for any co-pays or deductibles associated with the CCM program

¨     Informed, understand and acknowledge that the clinical information and care obtained within this program may be shared with other physicians and/or providers associated with their care.

When submitting the claim, there has not been any specific guideline stated as to how the codes have to be billed.  It would make sense that if this code can only be billed once per month, that the dates of claim would be spanned for the entire month being submitted (e.g.…  January 1 – January 31, x 1 unit 99490.)  The diagnoses submitted on the claim should be those that are clearly documented by the providers in regard to the CCM program and as required that a minimum of two (2) diagnoses are required to be noted in regard to the care and management of CCM.  (E.g. Renal Failure, COPD, Diabetes, etc)

As code 99490 is a new code for CPT in 2015, coders can expect to see claims that are delayed and/or requests for documentation proof of care provided, from 3rd party insurance payers.  CMS has stated that they will provide further information regarding documentation, and billing criteria through their MedLearn Matters program.  Medicare Advantage/PPO managed care programs that have Medicare beneficiaries in their programs would be required to follow Medicare’s lead.  However, private 3rd party insurance payers may not reimburse for this care, based upon a patient’s insurance contract with a particular payer.  In this case, coders/billers may want to inquire or pre-authorize the CCM care management with the private payers prior to providing CCM care to the patient.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CDIP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at or you can also find current coding information on her blog site:

Provided by:
By signing this Agreement, you consent to _______________________ (referred to as “Provider”), providing chronic care management services (referred to as “CCM Services”) to you as more fully described below.  
CCM Services are available to you because you have been diagnosed with two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at significant risk of further decline.
CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider’s practice to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you timely receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings.  The Provider will discuss with you the specific services that will be available to you and how to access those services.

Provider’s Obligations.  When providing CCM Services, the Provider must:  • Explain to you (and your caregiver, if applicable), and offer to you, all the CCM Services that are 
applicable to your conditions.  • Provide to you a written or electronic copy of your care plan.  • If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the 
effective date of the revocation.

Beneficiary Acknowledgment and Authorization.  By signing this Agreement, you agree to the following:  • You consent to the Provider providing CCM Services to you.  • You authorize electronic communication of your medical information with other treating providers 
as part of coordination of your care.  
• You acknowledge that only one practitioner can fur nish CCM Services to you during a thirty (30)-day period.  
• You understand that cost-sharing will apply to CCM Services, so you may be billed for a portion of CCM Services even though CCM Services will not involve a face-to-face meeting with the Provider.

Beneficiary Rights.  You have the following rights with respect to CCM Services: 

• The Provider will provide you with a written or electronic copy of your care plan.  

• You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then-current thirty (30)-day period of services.  You may revoke this agreement verbally (by calling ___________) or in writing (to _____________________________________).  

Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.

Beneficiary                                                                             Beneficiary’s Representative        and/or Caregiver (if applicable)
Signature: ________________________________  Signature:  ________________________________ 
Print Name:  ______________________________  Print Name:  ______________________________  
Date: ______________                                                    Date: ______________       

This sample form is for illustrative purposes only, and does not constitute legal advice. Please consult your legal counsel.

Sunday, February 1, 2015

CMS releases new MLN Matters article on modifier -59 use in 2015 -

CMS releases new MLN Matters article on modifier -59 use in 2015 -

Great info on this - 

HCPro:  CMS releases new MLN Matters article on modifier -59 use in 2015

Physician Practice Insider, January 27, 2015

On January 23, CMS released MLN Matters article SE1503, Continued Use of Modifier 59 after January 1, 2015, to alert physicians and other providers regarding the continued permissible use of the modifier.
With the article, CMS is aiming to eliminate confusion regarding its earlierChange Request (CR) 8863which took effect January 1. This CR established the new -X modifiers (i.e., -XE, -XP, -XS, and -XU) as appropriate for use in delineating subsets of modifier -59 use. Further guidance on the use of these modifiers is forthcoming, according to CMS.
Through the following new modifiers, CMS hopes to gain a better understanding of the types of services providers previously reported with the more generic modifier -59:
  • -XE, separate encounter, a service that is distinct because it occurred during a separate encounter
  • -XS, separate structure, a service that is distinct because it was performed on a separate organ/structure
  • -XP, separate practitioner, a service that is distinct because it was performed by a different practitioner
  • -XU, unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
In its initial transmittal, the agency states, “CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific -X{EPSU} modifier for billing certain codes at high risk for incorrect billing.”
The MLN Matters article clarifies this, saying, in short, “providers may continue to use the -59 modifier after January 1, 2015, in any instance in which it was correctly used prior to January 1, 2015.”
“What may be confusing for providers initially is that CMS is not going to stop recognizing modifier -59. In fact, the agency is only requesting the ‘more descriptive modifiers’ be reported, but it's only going to be a matter of time before CMS begins requiring the new modifiers,” Jugna Shah, MPH, president and founder of Nimitt Consulting, previously explained to HCPro. “What we do know is that what CMS is calling the -X{EPSU} modifiers cannot be reported alongside modifier -59. CMS says that it would be incorrect to include both modifiers on the same line.”