Chronic Care Management Services

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In the CY 2015 Final Rule, the Centers for Medicare & Medicaid Services (CMS) again acknowledged its support for primary care physicians and other qualified healthcare professionals.

As we [CMS] discussed in the CY 2013 PFS final rule with comment period, we [CMS] are committed to supporting primary care and we have increasingly recognized care management as one of the critical components of primary care that contributes to better health for individuals and reduced expenditure growth (77 FR 68978).

Effective with dates of service 1/1/2015, Medicare will begin paying for Chronic Care Management Services (CCM).

Based on how long it took CMS to develop educational materials explaining Transitional Care Management (TCM) Services, we believe it will be several months before CMS issues a transmittal detailing all the coverage and coding requirements for CCM.

Recognizing that not all physicians monitor the Federal Register or read the entire (or even portions of) Medicare’s Final Rule that details the changes for the following year, we decided to write this article to provide some of the highpoints we know today about the criteria required for CCM coverage as well as the code that should be used to bill for the service.

Information in this article has been researched and checked for validity, accuracy, and completeness based on the information available. Newby Consulting Inc. (NCI) uses reasonable efforts to provide accurate and up-to-date information; however, NCI accepts no responsibility or liability with regard to errors, omissions, misuse, or misinterpretations in the content of this article. NCI does not make any warranties or representations as to the accuracy or completeness of such information. The User's use thereof shall constitute an agreement by the User to release NCI and its employees from any liability for the content of this article, or for the consequences of any actions taken on the basis of the information provided.

The information included in this article should not be construed as an official source that includes all the details and criteria for reporting CCM services. This article is based on the following three (3) references:

Federal Register 11/13/2014 – Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015 Final Rule
Federal Register 12/10/2013 – Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014 – Final Rule
American Medical Association’s CPT and RBRVS 2015 Annual Symposium – 11/19/2014 – Presentation by Kathy Bryant, Director, Division of Practitioner Services, CMS

Physicians participating in one of the following CMS models/demonstration programs cannot bill CCM services for Medicare beneficiaries participating in the program; however, when appropriate, the practice can bill CCM services provided to Medicare beneficiaries who chose not to participate in the program

Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration
Comprehensive Primary Care (CPC).

We believe it is important to note that there are two sets of codes for chronic care management in CPT^® 2015:

Chronic Care Management Services

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, with the following 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;
comprehensive care plan established, implemented, revised, or monitored
- Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately

Complex Chronic Care Management Services

99487 Complex chronic care management services, with the following requirements:

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 significant 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
- Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not separately reported

+99489 Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure [99487]

Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex chronic care management services during a calendar month

CPT coding notes clearly state that providers cannot report both TCM and CCM for the same calendar month.

“If care management resumes after a discharge during a new month, start a new period or report transitional care management. If discharge occurs in the same month, continue the reporting period or report TCM.”

The CY 2015 Final Rule includes:

We [CMS] believe that the new CPT code 99490 appropriately describes CCM services for Medicare beneficiaries.

At this time, we [CMS] believe that Medicare beneficiaries with two or more chronic conditions as defined under the CCM code can benefit from care management and want to make this service available to all such beneficiaries.

Like all services, we [CMS] recognize that some beneficiaries will need more services and some less, and thus we [CMS] pay based upon the typical service. However all scope of service elements apply for delivery of CCM services to any eligible Medicare beneficiary. We [CMS] will evaluate the utilization of this service to evaluate what types of beneficiaries receive the service described by this CPT code, what types of practitioners are reporting it, and consider any changes in payment that may be warranted in the coming years.

We [CMS] are maintaining the status indicator “B” (Bundled) for CY 2015 for the complex care coordination codes, CPT codes 99487 and 99489.

Based on the above information, which Ms. Bryant confirmed during the CPT Symposium, the appropriate code for reporting CCM to Medicare is 99490.

Reporting 99487 with or without 99489 will result in the charges being denied as bundled even if no other services are reported on the same date of service.

As with all bundled services, physicians cannot execute a Medicare Advance Beneficiary Notice of Noncoverage (ABN) and bill the codes for the more intensive Complex Chronic Care Management Services and hold the patient financially responsible for the charge for the complex CCM service.

We appreciated Ms. Bryant’s clarification that CCM is not a “per beneficiary/per month payment.” This type of payment typically means the physician automatically receives the payment regardless of whether services were provided during the calendar month. The difference with CCM is that physicians/ other qualified healthcare professional must bill CCM using 99490 when the practice meets CCM billing requirements.

Thus, when CCM criteria are met for a given month, the practice must report CPT code 99490. The 2015 Indiana Medicare Fee Schedule for 99490 for dates of service 1/1/2015 through 3/31/2015 is $40.52!

Ms. Bryant explained that when the criteria for reporting 99490 is met (including at least 20 minutes of clinical staff time during the calendar month), the CCM code should be reported on the last day of the calendar month regardless of whether that date falls on a weekend or holiday.

Ms. Bryant presented a synopsis of the requirements for reporting 99490:

Beneficiary must have two (2) or more chronic problems
Based on clinical staff time – must be at least 20 minutes or more per calendar month
Not a per beneficiary / per month payment
Coinsurance applies
In order to bill
- Practitioner must inform beneficiary
- Obtain written agreement
- Must provide beneficiary a copy of the plan of care
- Only one practitioner can bill
CCM – Elements of Scope of Service
- Patient access, 24 hours a day, 7 days a week
- Continuity of care with specified member of team
- Care management for chronic conditions
- Management of transitions, including referrals
- Coordination with home and community based clinical service providers required to support a patient’s psychosocial needs & functional deficits
- Enhanced opportunities for patient communicate, including through secure messaging, Internet, etc.
Use EHR [electronic health record] that is acceptable for the EHR Incentive Programs as of December 31^st prior to each PFS [Physician Fee Schedule] payment year
- NCI Comments:
  - Ms. Bryant verbally explained that this means the practice must be using a certified EHR meeting meaningful use criteria for the previous year. Thus, if the practice adopted a certified EHR and attested for the incentive payment in 2013, on December 31, 2014, Stage 1 meaningful use criteria were applicable. Thus, for 2015 CCM services, you must be using a certified EHR that meets Meaningful Use Stage 1.
  - If you adopted and attested for the incentive payment in 2011, on December 31, 2014 Stage 2 meaningful use criteria were applicable. For 2015 CCM services, you must be using a certified EHR and meeting Meaningful Use Stage 2 requirements.
    - Ms. Bryant explained if the physician met and applied for the very narrow EHR Stage 2 Hardship Exception, Stage 1 requirements were applicable on December 31, 2014 which is sufficient for CCM services during 2015.
- Record certain core portions of the patient's medical record (demographics, problem list, medications and medication allergies and creation of clinical summaries informing care transitions)
- Document informed patient consent, provision of the care plan to patient, and communication with home and community based providers.
- One exception, for CY 2015, can use any electronic tool (other than fax) to create the care plan; make the care plan available 24/7 within the billing practice; share the care plan with other providers; and transmit clinical summaries in managing care transitions
CMS will allow “incident to” billing for CCM with “general supervision” when services are performed by clinical staff
- All other incident to regulations apply
- Also applies to non-face-to-face for TCM
- Reference CRT 410.26
- Due to the requirement of 24/7 patient access, CMS created a narrow exception to the direct supervision requirement

Payment for CCM does not include a face-to-face component. Physicians will separately report any evaluation and management (E/M) services using the appropriate level of care code to describe any face-to-face encounter that occurs during the calendar month. ‘

Caveat: You cannot count the clinical staff’s time related to the face-to-face E/M when determining whether at least 20 minutes of CCM was provided to the Medicare beneficiary.

We realize this is a very brief overview of CCM services. A detailed article is also available in the IAFP's Coding and Billing News section.