Chronic Care Management: Coding and Billing Criteria

Physicians may spend significant time managing care for patients with chronic health conditions. In 2015, CPT® introduced a code to report these services. To gain payment, both the patient and the documented care provided must meet extensive conditions.

DEFINITION

Per the AMA's CPT Assistant (October 2014):

Care management services are provided by clinical staff, under the direction of a physician or other qualified healthcare professional. These management and support services are provided to patients who reside at home or in a domiciliary, rest home, or assisted living facility, and may include establishing, implementing, revising, or monitoring the patient's care plan; coordinating the care of other professionals and agencies; and educating the patient or caregiver about the patient's condition, care plan, and prognosis.

The physician or other qualified healthcare professional provides or oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs, and instrumental and basic activities of daily living.

BILLING REQUIREMENTS

The basic requirements to report 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required 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 are defined within the code descriptor:

1. The services are time-based, and are billed once per calendar month.

Time may be non-contiguous and is totaled over the course of a calendar month. Care management time includes direct patient contact and non-face-to-face time dedicated to the patient's care. CPT Assistant (October 2014) stipulates that care management time may entail:

Time spent by the clinical staff in communicating either face-to-face or non-face-to-face with the patient and/or family, caregivers, other professionals, and agencies.

Time spent revising, documenting, and implementing the care plan, and/or teaching self-management.

Only time spent by the clinical staff of the reporting professional is counted toward the care management services time. When two or more clinical staff members are meeting about the patient, only count the time of one clinical staff member. Clinical staff time is not counted on the date of the first visit or on a day when the physician or qualified healthcare professional reports an E&M service (office or other outpatient services, codes 99201-99215; domiciliary, rest home services, codes 99324-99337; and home services, codes 99341-99350).

Care management activities performed by clinical staff typically include:

Communication and engagement with patient, family members, guardian or caretaker, surrogate decision makers, and/or other professionals regarding aspects of care;

Communication with home health agencies and other community services utilized by the patient;

Collection of health outcomes data and registry documentation;

Patient and/or family/caregiver education to support self-management independent living and activities of daily living;

Assessment and support for treatment regimen adherence and medication management;

Identification of available community and health resources;

Facilitating access to care and services needed by the patient and/or family;

Management of care transitions not reported as part of transitional care management (codes 99495, 99496);

Ongoing review of patient status, including review of laboratory and other studies not reported as part of an E&M service as noted above; and

Development, communication, and maintenance of a comprehensive care plan.

Only one provider (the provider assuming the care management of the patient) may report 99490, in a given month.

2. The minimum documented time spent must equal at least 20 minutes.

Chronic care management services totaling fewer than 20 minutes, per calendar month, may not be reported separately.

3. The patient must have two or more chronic conditions expected to last at least 12 months, or until the death of the patient.

Examples of chronic conditions include diabetes and advanced cardiovascular conditions such as congestive heart failure.

4. The patient's chronic conditions must place her or him at significant risk of death, acute exacerbation/decompensation, or functional decline.

5. The billing provider must establish and implement a comprehensive care plan, and that plan must be continuously monitored and revised, as necessary for patient care.

CPT Assistant (October 2014) explains:

A patient's care plan is a comprehensive plan of care for all health problems, which is based on a physical, mental, cognitive, social, functional, and environmental assessment of the patient. The following elements are typically included in the patient's care plan:

Patient's problem list, with expected outcome and prognosis;

Measurable treatment goals;

Symptom management;

Planned interventions;

Medication management;

Community and/or social services ordered, and how the services of agencies and specialists not connected to the practice will be directed and/or coordinated;

Identification of individuals responsible for each intervention; and

Requirements for periodic review, and, when applicable, revision of the care plan.

Please note this is not an exhaustive list; there may be other services required that are not included in this listing.

The Centers for Medicare & Medicaid Services (CMS), which sets coverage and payment rules for Medicare payers, requires that clinical staff services for chronic care management be provided under the general supervision of the billing provider (see Federal Register, Volume 79, No. 219, pgs. 67720-67721). General supervision means services are furnished under the directing provider's overall direction and control, but the provider's presence is not required while the service is performed.

REPORTING REQUIREMENTS

Other requirements to report chronic care management, as detailed by CPT Assistant (October 2014) and Federal Register, Volume 79, No. 219, Table 33, "Summary of Final CCM Scope of Service Elements and Billing Requirements," include:

• The patient must have access to care management services 24/7

• Continuity of care with a designated practitioner or member of the care team with whom the patient is able to have successive routine appointments

• Care management for chronic conditions, including systemic assessment and development of a patient centered plan of care

• Management of care transitions

• Coordination with home and community based clinical service providers

• Enhanced opportunities for a patient to communicate with the provider through telephone and secure messaging, Internet, or other asynchronous non-face-to-face consultation methods

CMS additionally requires that patients be given a (written or electronic) copy of their plan of care.

EXCEPTIONS

Chronic care management services may not be reported within the postoperative period of a surgery by the same billing provider. And, when claiming 99490 during the calendar month, the same provider may not separately code any of the following:

• Care plan oversight (99339, 99340, 99374-99380)

• Prolonged services without direct patient contact (99358, 99359)

• Anticoagulant management (99363, 99364)

• Medical team conferences (99366, 99368)

• Education and training (98960-98962, 99071, 99078)

• Telephone services (98966-98968, 99441-99443)

• Online medical evaluation (98969, 99444)

• Preparation of special reports (99080)

• Analysis of data (99090, 99091)

• Transitional care management (99495, 99496)

• Medication therapy management (99605-99607)

• End stage renal disease services (90951-90970)

 Medicare pays just over $40, per month, for chronic care management services. This may seem like a small amount for the care (and requirements) involved; but, you may already be providing the services defined by 99490, without compensation. By taking the time to systematize your documentation and reporting, you may be able to collect for your efforts, going forward.