On November 15, 2016 – the Centers for Medicare and Medicaid (CMS) announced the new changes to Chronic Care Management payment options by adding new codes and key improvements to the existing CCM billing methods and services.

Feedback from providers is the key reason for new codes. These changes are now set to implement on practices starting 2017 with an objective to enhance patient care and ensure hassle-free documentation for billing. Services offered by physicians will be based on the complexity of the patient’s need and will be billed under different CPT codes based on the service provided. Here is a summary of CCM and complex CCM codes.

CCM payment option till 2016

A physician will be paid $42 for 20 minutes of clinical staff time provided to patients with multiple (two or more) chronic conditions per calendar month under CPT 99490. Reimbursement for the provider will be the same if the clinical service time exceeds 20 minutes.

Changes in CCM codes effective from 2017

CMS recognized some patients may have complex chronic conditions and they might need additional care time. So, CMS addressed the need by introducing new codes 99487 and 99489 which will benefit those who need extra care and will also compensate providers with increased reimbursement options through new codes.

• CCM Code 99490
  Payment has increased from $42 to $43 for 20 minutes of clinical staff time.
• Complex CCM Code 99487
  60 minutes of CCM service for $94 that includes moderate to high complex medical decision-making.
• Add-On Complex CCM Code 99489
  This code is to use with 99487. Additional 30 minutes of service will be provided for bill amount $47.

In addition to the CCM codes, there are changes made in the service elements for enhanced care and administrative simplifications on billing.

CCM Service Changes for 2017

Initiating Visit

From 2017, initial visit is required for new patients or patients who have not enrolled their name for CCM services within past twelve months. Payment of $44-$209 to be billed by the billing practitioner for initiating visits.

For initial visit, CMS has introduced a new add-on code G0506 that includes extensive assessment and care planning performed by the billing practitioner beyond the usual efforts. A payment of $64 will be billed for this extensive initiation work- only once per patient per provider.

EHR and Technology requirements

CMS continues to stress on using certified EHR with a standard format (demographics, problems, medications, medication allergies, etc.) to record core clinical information.
It also states that the use of certified technology is no longer required for CCM documentation or care plan for sharing within or outside the network. Frequent access to care document is not required, given that providers have timely information on hand or for individuals providing CCM service after hours.
At the same time, CMS recommends physician to use certified technology as per the conditions of Medicare Physician Fee Schedule (PFS) payment to get points for the Quality Payment Program (QPP)
Beginning 2017, care plans can also be shared through fax as it has created more fuss last year among some providers when shared electronically.

Care Management

From now, the clinical summary is renamed as “continuity of care document(s)” and a care management plan copy given to patient requires no format. Usage of certified technology has been completely removed in this revision.
Beneficiary and caregivers are given the opportunity to communicate with the practitioner, not only through telephone, but also by means of secure messaging, Internet, or through any non-face-to-face communication methods.

24 hours access to care

Patients and caregivers are provided access to any of the physicians or other qualified professionals or clinical staff to make quick contact to address urgent care needs, not just for chronic care needs.
Continuous relationship with a designated member of the care team is improved to schedule quick and routine appointments.

Consent Change

Consent can be either verbal or written, but it must be documented in the patient record and the same should be explained for transparency.

The Centers for Medicare and Medicaid-recognized the importance of including a sustainable practice to manage care for patients suffering from multiple chronic conditions in the year 2015.
Medicare leveraged Physician Fee Schedule (PFS) options for CCM services offered to patients ailing from chronic conditions.

It’s been over 2 years since the implementation of Chronic Care Management services for patients.
CMS has closely observed the outcomes of those initiatives and has come up with plans that will increase the focus and funding towards the existing Chronic Care Management programs.

Let’s Understand CPT 99490

To be able to differentiate the purpose of the old codes from the new codes, one must understand the conditions for billing under CPT 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:

1. Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
2. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
3. Comprehensive care plan established, implemented, revised, or monitored

Assumes 15 minutes of work by the billing practitioner per month

What’s new in Complex CCM codes?

The primary limitation of CPT 99490 is the consulting time of 20 minutes, most practices felt the need to increase the consultation time for a patient.
Though CCM services resulted in positive outcomes, the results were far short of objectives.
Thus, they decided to increase the consulting time of CCM with new Complex CCM codes that can be used to provide 60 minutes of consulting in a calendar month and the duration of 60 minutes is billable.

Complex Chronic Care Management services, with the following, required elements:

1. 1. Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
   2. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
   3. Establishment or substantial revision of a comprehensive care plan
   4. Moderate or high complexity medical decision making
   5. 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month

How does the billing work?

A patient must be billed either for Complex Chronic Care Management codes or the already existing Chronic Care Management code.
The same patient should not be included or billed under both the codes, that way there’s more organized workflow for billing and reimbursement.

Reporting Expectations

Chronic Care Management codes CPT 99487, 99489, and 99490 are reported only once in every calendar month by the practitioner who carried out the care management, no more than one claim per month was allowed.
In the case of Complex Care Management, each month a practitioner is expected to review patient’s health condition and classify whether the patient would still be under the procedures of Complex Care Management or the existing Chronic Care Management codes.

This is a crucial practice to establish the health outcome of the patients given the importance and assistance for chronic conditions, in addition to that practitioners are expected to meet the quality metrics that are recommended by CMS.

Implementation of Comprehensive Care Plan at a practice level

New Chronic Care Management codes stress the necessity and induce the interest in creating an individual care plan for each of the patient’s for achieving better health outcomes.
It is important for the healthcare provider to record and assess patient health information at regular intervals.

An electronic form of secure patient information needs to be generated, based on which a physician can come up with a care plan that is required for the patients.
With technology companies extending their influence in healthcare, remote patient monitoring and real-time patient data can be gathered and put to best use. Creation and execution of care plan is one of the primary responsibility of the provider to adhere to quality metrics expected by the CMS.

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