Coding Questions: Definition of Direct Contact

Q:Are we now allowed to bill CCM 99490 if 20 minutes of work is documented but we did not actually have phone or online message contact with the patient/specialist/pharmacist? (Example: We spend 20 minutes faxing home health orders, reviewing consult notes, reviewing x-rays/labs, refilling medication, etc. but we never actually reached the patient by phone that month.)

A: Yes, direct contact is no longer specified under the revised CMS guidelines for CCM.

The original performance standards required by CMS starting in 2015 proved to be a barrier to physicians providing these services. Of the millions of patients that would qualify, less than 20 percent actually had CCM performed and billed.

In late 2016 CMS has simplified the requirements effective in January 2017 – chief among them being the elimination of the original 'contact-based' care. To count the time towards the 20-minutes of non-face-to-face time in the older system care had to be 'contact initiated.' This could be patient-doctor, doctor-doctor, pharmacy-doctor, lab-doctor, or other contact regarding or by the patient via phone or electronic communication. This is no longer the case.

You can also perform and bill for an initiation of CCM services during a face-to-face visit with the billing practitioner. Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506, comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services. There are codes for complex CCM as well. See the Medicare Medlearn CCM Guidance December 2016 for precise requirements.

Q: On the codes in the CPT manual that involve time, office visit codes, Medicare G-code screenings and psychotherapy – when they specify a time can I use the 'mid-point rule' from CPT to support the code?

A: There are different answers to that for some of the code types in your question. Although CPT does not say so, and in fact suggests otherwise – most providers don't use the 'midpoint rule' for EM office visits. This is covered in a CMS Claims Processing manual which reads: The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the evaluation and management code) and should not be "rounded" to the next higher level.

The G-code screenings, i.e. G0442, G0444, have '15 minutes' in their description. There is no actual Medicare policy of which I am aware that describes this as 'up to' 15 minutes.

Recent quarterly compliance newsletters have referenced recoupment of payments based on the lack of documented time for these G-codes as well as for psychotherapy services. Be very careful in your application of the midpoint rule.