Q&A: Chronic Care management and consult requirements

Q1:  Our office is billing the Chronic Care management code 99490 each month for some of our sicker patients, but I want to make sure we’re doing it right? What has to be documented to qualify?

A1:  The 99490 is designed to capture clinical staff time of at least 20 minutes in a calendar month that is devoted to the activities associated with chronic care management (CCM).

So first you need to be certain that the basic criteria are met: The two more chronic conditions that place the patient at risk are the care plan ‘established, implemented, revised or monitored’ and the qualifying activity of staff.

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Once that is determined, it’s about leaving a footprint in the medical record that outlines the CCM-related activity. What you need to make very obvious is the total time spent, the month, the identity (including credential) of the clinical staff involved-and just what specific CCM activities were performed/addressed.

Best practice is to have the CCM patient information in a ‘plan’ document. At the top of that document make a template that allows for monthly contact info, time, date, etc.

Below that, list the various named activities per chronic condition followed: 

eg. 1. Is patient Self-Monitoring?, blood sugar readings:  

Then cover the other components: 

• Assessment/support for treatment regimen adherence and medication management, 

• Ongoing review of patient status, including review of lab and other studies not reported as part of an EM service, 

• Patient and/or family caregiver education to support self-management, 

• Independent living and ADLs, 

• Communication with Home Health/other agency, 

• Facilitating access to care and services, 

• Management of Care Transitions. 

These are very clearly listed in the CPT manual in the subsection text just before code 99490. You don’t have to do all these things every month-these are just general categories of things you might do. If you have something in that section one month, add it. It might not happen again next month. 

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Focus your form on the identifying the interim Chronic Problem related activity that month. Often we see a plan written a year ago, copied endlessly, with a scrawled signature – and it gives absolutely no idea who did what – and what is going on with the chronic conditions.

So CCM codes aren’t for every time a patient calls for a refill, or needs a parking pass-it’s about supporting the management of specific chronic conditions. And don’t forget that CMS expects that there is real physician time directing or coordinating these staff activities… so this is meaningful, clinically necessary and relevant activity. Make sure it’s easy to see.

Continue to page 2 for the next question...

Q2: When billing consults, does the provider have to indicate in the medical record that they “CC” the referring provider.

Is there anything in writing for this? I have searched google and cannot find anything to give to the providers. We are getting denials from payers after medical records are reviewed.

A: The consult requirement isn't just a CC. Look in your CPT book-that's where the generally recognized consult requirements are. Aside from a documented request for the consults, the 'consultant's opinion… must also be documented… and communicated by written report'. And they mean back to whatever source requested the consult.]

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This language is really from the days of typing a letter, licking a stamp, and mailing it-it’s a little out-of-date. In settings where the medical record is shared between the requesting and consulting physicians you don’t need a separate report. This would include inpatient notes or large physician group practices  where the request for  and result of the consult is documented in the same EMR. 

That said, it just doesn’t hurt to document that the ‘results have been made available to the requesting provider’ (better with a name). That’s all the 'cc' was-an indication that something was shared.