The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 99490 - Chronic Care Management Services. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:

Top Denial Reasons:

• Failure to Return Records
• Documentation Submitted was Incomplete and/or Insufficient

Educational Resources

• How to Respond to ADR
• Signature Requirement Questions and Answers
• Required Documentation
• Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1

Education

Chronic Care Management

Chronic Care Management (CCM) is a service that is the oversight of educational activities/management of patients with chronic diseases and health conditions that are performed by physician and non-physician practitioners. This is billed as a monthly charge based on the amount of time spent during the given month.

To be eligible for CCM services, a beneficiary must have multiple (at least two) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

At the initiation of CCM, advance consent is required from the beneficiary to ensure that they are engaged and aware of any applicable cost sharing. This can be either verbal or written but must be documented within the medical record. Only one practitioner is able to provide CCM at one time.

The CCM service elements are as follows:

• Recording of Patient Health Information (demographics, problems, medications and allergies)
• A comprehensive care plan for all health issues
• Managing transitions of care and other care management services
• Coordinating and sharing patient health information
• Total time spent providing services per month

The care plan should be comprehensive and include all health issues, with particular focus on the chronic conditions being managed. The care plan should have a schedule for periodic review and revisions, when applicable.

Insufficient Documentation

When additional documentation has been requested to verify compliance with the CPT®/HCPCS code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient.

Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C).

Failure to Return Records

When the MAC requests documentation for prepayment review, it is the provider’s responsibility for the requested documentation to be received within 45 calendar days from the request. The MAC will not grant extensions to providers who need more time to comply with the request. Payment will not be made to any provider unless they have furnished the information as requested in order to determine the amounts due to the provider. Medicare will not pay for services unless they are deemed necessary and sufficient information is submitted that shows that services were provided. For payment, the services must be determined to be reasonable and necessary for the prevention or treatment of illness.

Refer to Social Security Act 1815(a), 1833(e), 1862(a)(1)(A).