CMS Payment Changes to Chronic Care Management

By: Jessica Fritel, CCS-P, CPC

Beginning January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) will make separate payments for chronic care management (CCM) as stated in the publication of the 2015 Medicare Physician Fee Schedule Final rule. Providers furnishing specified non-face-to-face services to qualified beneficiaries can be reimbursed once per month.

CMS has adopted CPT code 99490 (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month) to report chronic care management services when at least 20 minutes of clinical staff time are spent in care management activities. The required elements are: 

• Multiple (two or more) chronic conditions expected to last twelve months or more or until the death of the patient
• Chronic conditions that place the patient at significant risk of exacerbation, functional decline or death
• Comprehensive care plan established, implemented, revised or monitored

This code is reported only once per calendar month by the single physician or other qualified heath care professional who assumes the care management role with a patient. According to the rules only count the time of one clinical staff member when two or more clinical staff members are meeting about the patient. Do not count clinical staff time if it is on the date of the first visit or on a day when an evaluation and management (E/M) service code is reported by a physician or qualified health care professional.

Clinical staff time spent documenting, revising and implementing the care plan and/or teaching self-management can be counted toward the time spent in CCM as well as time spent communicating either face-to-face or non-face-to-face time with the patient and/or family, caregivers, other professionals and agencies.

Activities performed by clinical staff during care management may include: 

• Reviewing laboratory and other studies not reported as part of an E/M services
• Communicating with patient, family members, caretaker, other professionals, guardian and/or home health agencies, regarding aspects of care as well as home health agencies and other community services used by the patient
• Gathering registry documentation and health outcomes data
• Helping the patient and/or family gain access to services and care needed
• Providing education to the patient or caregiver about self-management, independent living and daily living activities
• Developing, maintaining and sharing a comprehensive care plan
• Managing transition care not reported as part of transitional care management (CPT codes 99495, 99496)
• Identifying health and community resources available
• Assessing for adherence to treatment regimen and drug management

The care management practice/office performing the CCM must have the following capabilities: 

• Provide around-the-clock access to physicians or other qualified health care professionals for patients and caregivers
• Provide continuity of care with a member of the care team with whom the patient can schedule routine appointments
• Provide access and management for timely follow-up after a facility discharge or a visit to the emergency department
• Use an electronic health record system so providers have timely access to clinical information
• Identify patients requiring care management services using a standardized methodology
• Identify patients who require services using an internal care management process so they can start receiving them in a timely manner
• Standardize a form and format for the practice to be used in the in the medical record
• Educate and engage patients and caregivers in addition to coordinate care among all service professionals as appropriate for each patient 

The physician or other qualified health personnel designated to perform CCM may also report additional E/M services performed during the same calendar month by using the appropriate E/M code(s). However, the following services are integral to the performance of care management services (codes 99487-99490) and may not be reported separately if performed by the same individual during the month for which codes 99487-99489 are assigned: 

• Care plan oversight services (codes 99339, 99340, 99374-99380)
• Prolonged services without direct patient contact (codes 99358, 99359)
• Anticoagulant management (codes 99363, 99364)
• Medical team conferences (codes 99366, 99368)
• Education and training (codes 98960-98962, 99071, 99078)
• Telephone services (codes 98966-98968, 99441-99443)
• On-line medical evaluation (codes 98969, 99444)
• Preparation of special reports (code 99080)
• Analysis of data (codes 99090, 99091)
• Transitional care management services (codes 99495, 99496)
• Medication therapy management services (codes 99605-99607)
• End stage renal disease services (codes 90951-90970)

Codes 99487-99489 are not reported if CCM services are performed in the postoperative period of a surgery performed by the same individual. All other services may be reported.

Adopting CPT code 99490 and paying for CCM is one way Medicare continues to emphasize primary care. This is only one part of a multi-faceted CMS initiative to improve access to primary care for Medicare beneficiaries.

For additional information or questions, please contact Jessica Fritel or your Eide Bailly representative.