Billing for Chronic Care Management Services

A 19th century novelist described the work of physicians this way: "Perhaps in no career has a man to work harder for what he earns, or to do more work without earning anything." Anthony Trollope wrote those words in 1864, before managed care and relative value units. (And, before medical schools were filled with women.)

Primary-care physicians are resigned to doing work for which they don't get paid, such as writing a letter explaining why the patient needs a medicine that isn't on the formulary. This makes it all the more exciting to have a benefit that pays primary-care physicians for coordinating the care of medically complex patients. Starting in 2015, CMS and many commercial payers reimburse for this non-face-to-face service.

The CPT code is 99490: chronic care management services (CCM), at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare 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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and

• Comprehensive care plan established, implemented, revised, or monitored.

After patient eligibility, the first requirement for CCM is that the physician or advanced practitioner develop a care plan at either the Welcome to Medicare visit, an annual wellness visit, or a comprehensive E&M service. CMS has not defined a comprehensive E&M service for this purpose. This plan is not a static plan, locked in a visit note, but is a plan that can be updated and shared with other healthcare providers electronically. After developing this patient-centered plan, the practice manages care transitions and coordinates the patient's care with other providers or community services. In a month in which the clinical staff time (not physician or advanced practitioner time) is 20 minutes or more, the practice may report CCM. It is not a per member, per month benefit. That is, if the staff spends only 15 minutes in June, the practice may not report CCM in June. Like many cell phone data plans, the minutes don't roll over to or from a prior or future calendar month. In order to bill the service, the practice must explain it to the patient and get written informed consent to provide the service. The patient will be liable for a copay and the annual deductible if there is no secondary insurance. All clinical staff whose time is counted toward the 20 minutes must have electronic access to the care plan. The practice must have the capability of sharing this care plan digitally with other healthcare professionals who are involved in the patient's care. Faxes do not qualify. Secure messaging would qualify. The practice needs to identify a primary-care provider who is available to see the patient and must provide on-call access for the patient.

One basic hurdle is the EHR software. The practice needs the capacity to record the care plan electronically, provide access for all staff members who bill CCM time, provide the care plan digitally for other providers who share the care of the patient, and track and record the time and activities spent in the CCM.

The reimbursement isn't large. It is about $40. Let's consider a physician with 300 eligible patients and assume that the clinical staff spends 20 minutes managing each of these patients for six months out of the year. The potential revenue is $72,000 a year or $6,000 monthly.

Let's assume that the clinical staff meets the 20-minute threshold for 150 eligible patients and spends only10 minutes with the other 150 eligible patients in a given month. That would take 75 hours of staff time. Some of those patients may take 30 or 40 minutes, but the reimbursement is the same and there will certainly be nursing time taken up in activities that don't qualify for CCM. A practice needs to examine the potential revenue and the costs of providing the service to evaluate the financial feasibility of participating. Also, before financial considerations, the primary-care practice must evaluate if it has the staff available to provide these CCM services.

Additional resources:

There are two sources of information more detailed than this review. The first is the CPT book itself, which describes the coding rules for using 99490 and lists the codes that may not also be reported in the same month as CCM. CMS also has a PowerPoint presentation, audio recording, and fact sheet about CCM.