These are strange and unprecedented times we are living in. At the time of this writing, plans for reopening the US economy during the COVID-19 pandemic are still being discussed. Many businesses that have been deemed nonessential are closed, and many healthcare providers have made changes to provide only essential and emergent care to patients to slow the spread of the pandemic in the US. Many payers have made drastic policy changes to allow providers the flexibility to continue to provide care via telephone or video calls and still obtain reimbursement.
Payer reimbursement policies changed so rapidly from mid-March to mid-April that billing departments and providers across the nation have struggled to keep up with the latest information about which services are covered and how to bill for them. It’s impossible to predict what our healthcare system will look like on the other side of this pandemic, but it is inspiring to see the ingenuity and creativity behind efforts to keep the people of our nation safe.
In the last edition of From the Field, we discussed the basic elements of Chronic Care Management (CCM) services. In this edition, we will discuss the codes that represent CCM services as well as several CCM frequently asked questions. There are procedure codes for three separate levels of CCM services and one add-on procedure to reflect extra time spent on an individual patient’s CCM services. Below are descriptions of the three code levels and the add-on code.
Level 1 (CPT 99490) encompasses at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional per month spent on CCM services when the following are present:
- Two or more chronic conditions that will last at least 12 months and place the patient at significant risk of death, functional decline, etc.
- Comprehensive care plan established, implemented, revised, or monitored.
Level 2 (CPT 99491) encompasses 30 minutes of CCM services provided personally by a physician or other qualified healthcare professional per month when the following are present:
- Two or more chronic conditions that will last at least 12 months and place the patient at significant risk of death, functional decline, etc.
- Comprehensive care plan established, implemented, revised, or monitored.
Level 3 (99487) Complex CCM services encompasses 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per month.
Complex CCM services include the following elements:
- Two or more chronic conditions that will last at least 12 months and place the patient at significant risk of death, functional decline, etc.
- Establishment or substantial revision of a comprehensive care plan.
- Moderate or high complexity medical decision making.
For each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional per calendar month, there is an add-on code (CPT 99489) that can be reported to represent the additional time spent on a patient’s CCM services.
CCM Frequently Asked Questions
Below are just a few of the questions that I have received in recent months regarding CCM services. There are many online resources readers may find helpful, and as always, I welcome reader questions.
Q: Are there services that cannot be billed under the Medicare physician fee schedule during the same calendar month as CCM?
A: Yes, Transitional Care Management (TCM), Home Health Care Supervision, Hospice Care Supervision, and ESRD Monthly Capitation Payment services may not be billed by the same provider in the same service period as CCM services. While nephrologists may not bill for CCM services for their ESRD patients, they may have stage 4 kidney failure patients that have qualifying chronic conditions that would benefit from CCM services.
Q: Is a new patient consent required each calendar month or annually?
A: A new consent is only required if the patient changes billing practitioners.
Q: In the event the patient dies during the service period, can CCM services still be billed?
A: CCM services can be billed if the patient dies during the service period, as long as the required service time for the code and all other requirements were met.
Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD dialysis programs, nephrology practices, and vascular access. Your questions are welcome and she can be reached at [email protected], 801.775.8010, or via Sceptre’s website, www.sceptremanagement.com.
