Chronic Care Management Services

Beginning January 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (MPFS) for the American Medical Association (AMA) Current Procedural Terminology (CPT) code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions. CPT code 99490 is payable under the Outpatient Prospective Payment System (OPPS) when certain requirements are met.

CPT code 99490 - Chronic care management (CCM) 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 required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until death of patient
  • Chronic conditions place patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored

Practitioner Eligibility

Physicians and the following non-physicians may bill for new CCM service:

  • Certified Nurse Midwives
  • Clinical Nurse Specialists
  • Nurse Practitioners
  • Physician Assistants

Eligible practitioners must act within their State licensure, scope of practice, and Medicare statutory benefit.

Non-clinical staff time cannot be counted. Practitioners may use individuals outside the practice to provide CCM services, subject to the MPFS incident to rules and regulations and all other applicable Medicare rules.

Supervision

Clinical staff may provide the CCM service "incident to" the services of the billing physician (or other appropriate practitioner) under the general supervision of a physician.

Patient Eligibility

Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient.

CMS requires the billing practitioner to furnish an evaluation and management (E&M) visit, Annual Wellness visit, or Initial Preventive Physical Examination (IPPE) to the patient prior to billing the CCM services.

Patient Agreement Requirements

A practitioner must inform eligible patients of the availability and obtain consent for the CCM service before furnishing or billing the service.

Patient consent requirements include:

  • Inform patient of availability of CCM service and obtain a written agreement to have services provided
  • Document CCM service discussion in patient's medical record and note patient's acceptance or denial of services
  • Inform patient that only one practitioner can furnish and be paid for services provided during a calendar month

The following agreement process should include a discussion with patient about:

  • What the CCM service is
  • How to access elements of service
  • How patient's information will be shared among practitioners and providers
  • How coinsurance and deductibles applies to these services
  • How to revoke service

Care Plan

  • Create a patient care plan based on physical, mental, cognitive, psychosocial, functional, and environmental assessment
  • Provide a written or electronic copy of care plan and document its provision in medical record
  • Ensure care plan is available electronically at all times
  • Share care plan electronically outside facility as appropriate

Comprehensive Care Plan

A comprehensive care plan for all health issues includes, but is not limited to:

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions and identification of individuals responsible for each intervention
  • Medication management
  • Community and/or social services ordered
  • Description of how services of agencies and specialist outside facility will be coordinated
  • Schedule for periodic review and revision of care plan, when applicable

Access to Care

  • Ensure 24 hours a day, 7 days a week access to care management services is available
  • Ensure continuity of care with a designated practitioner with whom patient is able to get continual routine appointments
  • Provide enhanced opportunities for patient and any caregiver to communicate with practitioner regarding patient's care. Can be done via telephone, secure messaging, secure internet, in compliance with Health Insurance Portability and Accountability Act (HIPAA)

Manage Care

Care management services such as:

  • Systematic assessment of patient's medical, functional, and psychosocial needs
  • System based approaches to ensure timely receipt of all recommended preventive services
  • Medication reconciliation with review of adherence and potential interactions
  • Oversight of patient self-management medications

Mange care transitions between and among healthcare providers and settings, including referrals to other providers, including:

  • Providing follow up after an emergency department visit and after discharges from hospitals, skilled nursing facilities, or other healthcare facilities
  • Coordinate care with home and community based clinical service providers.

Other Billing Requirements

CPT code 99490 cannot be billed during same period as:

  • CPT codes 90951-90970 (End Stage Renal Disease (ESRD) services)
  • CPT codes 99495-99496 (transitional care management)
  • HCPCS codes G0181, G0182 (home health care supervision/hospice care supervision)

Payment

The CMS pays for new CCM service separately under MPFS. Access MPFS Look-Up Tool on CMS website

CCM and CMS Advanced Primary Care Initiatives

Medicare will not make duplicative payments for the same or similar services for beneficiaries with chronic conditions already paid for under the various CMS advanced primary care demonstration and other initiatives, such as the Multi-payer Advanced Primary Care Practice (MAPCP) or the Comprehensive Primary Care (CPC) Initiatives.

 

Last Updated Fri, 28 Feb 2020 13:12:01 +0000