Monday, January 2, 2017

Chronic Care Management codes – post implementation… Are you missing out?

Chronic Care Management codes – post implementation… Are you missing out?

December 4, 2016

In January of 2015 CMS developed codes for chronic care management.  This was based on the premise that more careful oversight would result in better care and reduced spending in regard to patients with chronic conditions.  The (CPT) code 99490, for non-face-to-face care coordination services was developed for this reason.

As a time-based code there are some criteria that need to be met, but the amazing part of this code implementation is it does not require face to face time with the patient.  This is all done as “non” face to face time.    CPT and CMS both require these specifics to be met :

At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month,  Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
Chronic conditions must  place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
A comprehensive care plan is to be established, implemented, revised, or monitored.

Some practitioners were concerned with the comprehensive care plan, but this list below from CMS helps with the clinical documentation of establishing and implementing this care plan.

Problem List
Expected Outcome and Prognosis
Measurable Treatment Goals
Symptom Management
Planned Interventions and Identification of those services/individuals responsible/needed for each intervention
Medication management
Community/Social Services Ordered
A description of how the services/agencies outside of the practice will be coordinated
A Schedule for periodic review and revision of the care plan

However, there are some down-side items that have been discovered over the last 18 months.   One of the findings is that CPT code 99490 cannot be billed during the same service period as CPT codes 99495–99496 transitional care management;  HCPCS codes G0181/G0182 home health care supervision/hospice care supervision;  or CPT codes 90951–90970 End-Stage Renal Disease services.  If you are unsure if a code can/cannot be billed with the 99490 CCM code,  always run a CCI edit scrub or review the CCI bundling edits to ensure that you can bill the CPT code 99490 with a specific code.  This will also confirm if the codes are truly bundled, or if they can be over-ridden with a modifier added to the claim.

Another issue of concern from coders is what place of service (POS) should be reported on the physician claim.  Physicians/Practitioners must report the POS for the billing location as the same place where a face-to-face office visit with the patient would take place.  (eg POSs 11-office etc.)  Again, if the care is furnished in the hospital outpatient setting, (eg  provider-based locations) then they should be reported as the appropriate place of service for a hospital outpatient setting.   In addition, Medicare and CPT allow billing of E/M visits during the same service period as CPT 99490.  If an E/M visit or other E/M service is furnished on the same day as a CCM service, the clinical documentation  needs to clearly define  the allocation of total time between the CCM CPT 99490 code and the E/M code(s).

Medicare guidelines state that only one E/M service can be billed per day unless the criteria is  met for the usage of modifier -25, and the designation of “time”  cannot be counted twice, regardless if the time denoted from the provider is  face-to-face or  non-face-to-face time.

Face-to-face time that can be/or is used to calculate the E/M service that was provided by the physician cannot be counted towards CPT 99490.   However, the time spent by clinical staff providing non-face-to-face services within the scope of the CCM service can be counted towards CPT 99490. If both an E/M and the CCM code are billed on the same day, modifier -25 has to be reported, and appended on the CCM claim.

The other issue of concern from coders is if the provider spends greater than 20 minutes of non-face to face time, that there is not a code or an “add on” code to designate the additional non-face to face time spent.  The CPT code criteria and verbiage are very specific in regard to code 99490.  The CPT criteria state “Code 99490 is reported when, during the calendar month, at least 20 minutes of clinical staff time is spent in care management activities.”   This means that even if a practitioner spends more than 20 minutes, there is no additional reimbursement or coding option for more “units” or the addition of an “add on” code for additional time based reimbursement.

Another concern from  medical billers and coders, is repayment for the physician providers within their practice, if another physician practice or specialty practice have billed for this code within the same month.  Medicare will only pay for this code once per calendar month.  If more than one provider/specialty submits a claim on the patient, the first claim to be received by the insurance carrier will be paid.  Any other claims for code 99490 will be denied reimbursement.  The code 99490 can be billed by any provider of care; however, again only 1 provider will be paid for the claim.    This can be problematic if the patient is being cared for by multiple providers and specialties.  Communication between the providers is necessary to provider not only good care, but to ensure that each provider is coding and billing appropriately.

As billers and coders, it is our job to code and bill appropriately for the care being provided.  Code 99490 was implemented to incentivize providers to manage and communicate more thoroughly between the multiple providers for patients with extensive and complicated chronic conditions.  Unfortunately, as a biller/coder, it may be hard to “find” this care documentation within the chart.  In addition to charting the “time” the diagnosis for the two (or more) chronic conditions must  be documented and clearly connected as medically necessary  for this oversight care.

In the last 18 months, since code 99490 has been implemented in the CPT code set, one of the biggest issues that has come to the forefront is physician reluctance to document and bill for the 99490 CCM code.  Many providers have implemented the basic criteria into their electronic health records, yet are not utilizing this method to document and bill for cod 99490.  The EHR is the most effective way to meet and guarantee that the fulfillment of all criteria for billing of this code is met.  However, the usage of a basic “table” format into a hard-copy chart or file can be just as effective and easy to use.  With either system, it still allows the biller/coder to easily audit and bill for this code.  (see end of article for a template for hard copy documentation)

Another “bonus” of this code, is if the practice utilizes mid-level providers of care (as listed below) those providers can provide this care management without a huge amount of impact to the physician providers of care.
Physician Assistants
Nurse Practitioners
Certified Nurse Midwives
Clinical Nurse Specialists

For those physician providers that have been billing for this code, for 20 minutes of work time, the national Medicare payment amount on this code for fiscal year is  $40.82, and the proposed payment for 2017 is $42.21.  According to CMS, in the fiscal year of 2015, only 275,000 Medicare beneficiaries received (and CMS paid for)  this service under code 99490.  Considering how many Medicare beneficiaries are enrolled and receiving Medicare services (approx. 54 million)  275,000 services provided with code 99490 is a very small percentage of total Medicare beneficiaries that could have received these services.  At first glance, it seems that $40.82 as the reimbursement for this service is small, however, this can add up quickly if you have a large Medicare population.  Code 99490 can  easily be provided, documented and billed for to increase the revenue stream into the practice.

It remains, however, the area of continued concern from providers is they must also allow the patient to “Opt in” and consent to have oversight for this care.  This can be problematic, as this is a non-face to face coordination of care, and patients may view this as a “charge” for a service not rendered appropriately, as they did not physically “see” the provider.  Patients have complained to their providers for having to pay for this “invisible” service.  Again, it is imperative that the physician provider communicate clearly to the patient regarding this service and allow the “opt in”  or “opt out”.  Physicians also stated concern, if they would be able to ensure or maintain a 24-hour-a-day, 7-day-a-week (24/7) access to care management services as required by the CMS guidelines.

As a coder, billing code 99490  is one way to help your physician actually get paid for time spent performing this care management service.  This service can include telephone calls, coordination of continuing services, and collaboration with specialty physicians which are services that are not normally paid for, or bundled in traditional E&M services.  In addition to providing good patient care, the billing/coding of CCM code 99490 that can also help the practice revenue stream and enhance the patients overall care.  It is your expertise of you, the coder/biller that can pull this all together with your providers.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, 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:

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