Complex Chronic Care Management Services 99487 +99489 (part 2 of 2)

Complex Chronic Care Management Services 99487 +99489

(Part 2 of 2)

December 21, 2016

As we discussed in the article for chronic care management services (code 99490) these patients that utilize these services are those that are generally chronically ill who have continuous and/or ongoing episodic "chronic medical diagnoses.  The majority of these patients are receiving these services within an assisted living facility, some still reside at home, and others are in a full-service nursing care center.

Complex Chronic Care Management is not reported by location, but are provided in coordination with other care providers and at times, performed by clinical staff that is not necessarily an MD or DO.  It is not uncommon to see the clinical staff document, develop, implement, and revise care plans for these complex chronically ill patients.  However, this takes place under the direction of the physician and/or other qualified health care professionals such as a Physician Assistant, or Nurse Practitioner.

CPT in 2017 denotes the codes 99487 with add-on code 99489 for the reporting of Complex Chronic Care Management codes.   (note: Code 99488 has been deleted)  The acronym "CCCC" which stands for complex chronic care coordination – is often noted in the clinical documentation to report these services.  Patients needing complex care coordination often have many providers involved with their care, which can include physical therapy, psychiatric and behavioral services, social and home care services, in addition to on-going internal medicine, specialty services for cardiology, orthopedics, neurology, urology, etc.

The 99487 and the add on code 99489 that we utilize from CPT is coded similar to those codes such as critical care services and is a time-based service in addition to other qualifiers that must be met. 

CPT created these codes to assist physicians in billing for time spent coordinating the many different services and medical specialties needed to effectively provide are for these complex patients' and their medical condition(s), psychosocial needs and normal every-day activities. 

When billing for complex chronic care management services CPT has outlined very specific guidelines.  These guidelines within CPT state that complex chronic care management services are provided during a "calendar month" timeframe and include criteria to be met

·         Establishment OR substantial revision of a comprehensive care plan that includes:

o   Medical, Functional and/or Psychosocial problems requiring medical decision making of moderate or high complexity; 

o   Includes clinical staff care management services for at least 60 minutes under the direction of the physician

·         CPT also states that these patients are treated with three or more prescription medications, and receiving other types of therapeutic interventions such as PT or OT. 

The usage of these codes may NOT be reported if the care plan is "unchanged" or requires only a "minimal" change (such as a medication change or an adjustment to a treatment modality is ordered).

In addition the patients that require complex chronic care management services have multiple illnesses, multiple medication use, and the inability to perform activities of daily living, requirements for a care-giver and/or repeat admissions to an inpatient facility or emergency department.  Normally they will have 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, and the patient is at risk of death, acute exacerbation/decompensation or functional decline.  These patients are truly at risk for mortality/morbidity issues. 

CPT has given us a handy table to code from for this time based service: 

Total Duration of Staff Care Management Services	Complex Chronic Care Management
Less than 60 minutes	Not reported separately (Use standard E&M)
60 to 89 minutes (1 hour – 1 hour 29 minutes)	99487
90 – 119 minutes (1 hour 30 minutes – 1 hour 59 minutes	99487 and 99489 x 1
120 minutes or more (2 hours or more)	99487 and 99489 x 2 and 99489 for each additional 30 minutes

Since CPT deleted code 99488 if the physician has a face to face visit with the patient during this same timeframe within the month, the coder should bill with the appropriate E/M code.  The physician or provider also needs to include a "separately identifiable' way for the coder to see the documentation of this care management so this time-based service can be accurately coded and viewed to ensure that the clinical reporting is valid and meets all criteria in addition to the notation of time.  CPT has also included the caveat "if the physician personally performs the clinical staff activities, his/her time may be counted toward the required clinical staff time to meet the elements of the code".

CMS is proposing for 2017 the following RVU allocation on these two codes as shown in the table below.  With CMS including RVU's on these codes, it is much more incentivizing for physicians to perform, document and bill for the complex chronic care management services.

CMS Proposed Work Values for fy2017

HCPCS	Descriptor	Current work RVU	RUC work RVU	CMS work RVU
99487	Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.;	0.00	-	1.00
HCPCS	Descriptor	Current work RVU	RUC work RVU	CMS work RVU
99489	Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, establishment or substantial revision of a comprehensive care plan, moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month	0.00	-	0.50

As billers and coders, it is our job to code and bill appropriately for the care being provided.  Code 99487 and the add on code 99489 were 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.  The medical necessity will be borne out with clear documentation of the provider and the morbidity/mortality of the complex diagnoses being managed. 

If there is a question regarding the time spent, or problems being cared for communication with the provider is vital.  You can always help your provider get you the appropriate documentation by creating a "clinical documentation checklist" that includes the pertinent information that you need, or have this information readily available in the electronic medical records or health care record.  The most helpful clinical documentation includes:

·         A clear description of the condition (diagnosis)

·         New pertinent clinical findings or outcomes

·         New or substantially changed diagnostic and/or therapeutic procedures and services

·         New or substantially changed medications/medication listing

·         Changes in severity of patient condition

·         Clear documentation for the "Month" being code for, and a clear documented record of time spent performing the above.

As the coder/biller, it is your help and expertise, coordinated with the physician and clinical providers, to pull in all the "pieces" which will ensure the utilization of the Complex Chronic Care Management codes of 99487 and 99489 make a difference in the physician practice revenue stream and enhance the patients' overall care. 

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 webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.