Why the Need for the Chronic Care Management Program?

The Financial & Human Cost of Chronic Disease in The United States is Staggering. Check Out The Chart Below.

G4947 Gasd4947
Path34 G4asd914
G4676 Gasd4676
G4990 5 Care Vitality - Chronic Disease
G5136 Care Vitality - Chronic Condition
G5SD0 G5ASSD0

What is Chronic Care Management (CCM) CPT 99490?

Medicare pays separately under the Medicare Physician Fee Schedule for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions. The average reimbursement per qualifying patient per month is $42 and can reach up to $142 for complex patients.

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care 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.

If 60 minutes or more of clinical staff time are billed per calendar month two additional CPT codes for Complex CCM may be used in place of CPT 99490.

Services for billing CPT 99490 are very similar to billing Complex CCM.  However, to bill Complex CCM codes it requires medical decision making of moderate to high complexity as well as “establishment of substantial revision” of the care plan versus the “establishment, implementation, revision or monitoring” of the care plan for CPT Code 99490.  

CPT Code 99487 can be billed if 60 minutes of clinical staff time directed by a physician or qualified health care professional, per calendar month to provide CCM services and pays approximately $93.67. 

CPT Code 99489 can be billed for each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month for CCM services and pays approximately $47.01. (List separately in addition to code for primary procedure)

New conditions are being added as CMS has elaborated on the definition of a chronic condition. Examples of chronic conditions include:

  • Alzheimer’s disease and related dementia
  • Chronic Kidney Disease
  • Cancer (almost all cancers)
  • Glaucoma
  • Anemia
  • Asthma
  • Chronic Obstructive Pulmonary Disease
  • Diabetes
  • Hypertension
  • Osteoporosis
  • Chronic Pain & Fatigue
  • Atrial Fibrillation
  • Obesity Stroke
  • Cataract
  • Arthritis (osteoarthritis and rheumatoid)
  • Autism Spectrum Disorders
  • Depression
  • Heart Failure
  • Ischemic Heart Disease
  • Migraine/ Chronic Headache
  • Fibromyaglia

Physicians and the following non-physician practitioners may bill the new CCM/TCM service:

  • Certified Nurse Midwives
  • Clinical Nurse Specialists
  • Nurse Practitioners
  • Physician Assistants

Only one practitioner may be paid for the CCM service for a given calendar month.

Note: Eligible practitioners must act within their State licensure, scope of practice and Medicare statutory benefit. The CCM service may be billed most frequently by primary care physicians, although specialty physicians who meet all of the billing requirements may bill the service. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical physiologists, podiatrists, or dentists, therefore these practitioners cannot furnish or bill the service. However, CMS expects referral or consultation with such physicians and practitioners by the billing practitioner to coordinate and manage care.

CMS provided an exception under Medicare’s “incident to” rules that permits clinical staff to provide the CCM service incident to the services of the billing physician (or other appropriate practitioner) under the general supervision (rather than direct supervision) of a physician (or other appropriate practitioner).

We provide all the tools and resources needed to Participate in the CCM Program and allow you to begin receiving the Financial Benefits quickly while improving the health of your chronically ill Medicare patients. We do all the work, which gives you access to this Incentive Money without placing burden on your practice or your staff!

Care Vitality - CCM Explainer Video

What are the Benefits of CCM?

Providers

Make up to $300,000 a year gross annual revenue

We schedule all the CCM patients Preventative and Health Maintenance appointments increasing in-office encounter revenue 20%- 30% on average

Improve your quality measures for other incentive programs

Stay focused on in-office patient care and let our staff provide the non-face-to-face burden of your chronically ill Medicare patients

Free up time to either enjoy time outside of the office or potentially see more patients

Satisfied patients are more likely to adhere to their care plans and continue to be treated by providers that are invested in improving their health

Patients

Care Management services provide a continuum of care for patients to improve patient outcomes and reduce total cost of care

Providing 24/7 access to care provides patients with the support needed to better manage their chronic conditions and overall quality of life

Continued care management of the patient improves adherence and patient literacy so they can take an active role and proactive approach to managing their overall health including diet, exercise and nutrition

Care management support addresses gaps in care, provides assistance managing chronic conditions and episodic problems that may otherwise go unaddressed, resulting in poor patient outcomes, costly hospitalizations, procedures or additional chronic disease states

Improved patient adherence and compliance starts with education and literacy. By providing essential patient-centric information patients can understand the need for compliance and be better informed to make the correct decisions in self- management

Patients participating in the CCM program have access to 24/7 care support provided by our RN Clinical Care Team

What are the Challenges to Value-based Care?

Research studies have demonstrated time and again that providing care management improves patient outcomes and reduces total cost of care. CMS recognizes these numerous studies conducted over the last decade that demonstrate that Care Management provides patients with chronic conditions with the much needed support and health coaching to improve quality outcomes and reduce total cost of care. However, there are several challenges that have prevented many providers from participating in the Chronic Care Management Program and other value- based care initiatives.

Burden Of Time

Burden Of Time

Managing Internal Resources

Managing Internal Resources

Protecting (ePHI)

Protecting (ePHI)

Cost of Resources

Cost of Resources

Liability

Liability

Compliance

Compliance

Third-Party software

Third-Party software

Documenting Appropriately

Documenting Appropriately

Fear of Penalties

Fear of Penalties

Hiring the Right Resources

Hiring the Right Resources

What are Outcomes of Providing CCM Services?

CCM Engagement & Interactions

Care Vitality - Care Continum

Additional FAQs

Do you have any sense of what percentage of eligible patients would engage in this type of service? Is there a benchmark for participation in CCM programs?

The Center for Primary Care (CPC), featured in the webinar, estimates 75% of eligible patients will consent to participate in CPC’s chronic care management program. Of those, they anticipate approximately 50% will remain compliant and meet the requirements to bill CMS.

CPC provides one reference point for providers interested to forecast program impact. However, patient engagement rates can vary dramatically based upon a host of variables. For this reason, it is critical that providers have a deliberate strategy to educate beneficiaries and secure their consent. To discuss program modeling or for further information related to patient engagement, please contact us directly.

How do you identify all the qualifying Medicare patients?

We use our sophisticated software tool to identify all your qualifying CCM patients, we also have experience working on over 150 EHR, PMS and Patient Portal systems, which makes us intimately familiar with the features and functionality of the technologies you have in place and we have the experience to pull the reports from your systems in order to cross map with our tool to determine all your qualifying CCM patients.

Since patients are required to pay a coinsurance under this program, won’t that dissuade most from participating?

Only one in 10 beneficiaries relies solely on the Medicare program for health care coverage. The rest have some form of supplemental coverage to help with medical expenses, so 90% of your patients may not have to pay out of pocket for the co-pays.

Is there a list of chronic conditions that qualify under the program?

CMS maintains a Chronic Condition Warehouse (CCW) that includes information on 70+ specified chronic conditions. However, the CCW list is not an exclusive list of chronic conditions; CMS may recognize other conditions for purposes of providing CCM.

Will Medicare Advantage (MA) plans reimburse for CCM? What about commercial payers?

Medicare Advantage plan is required to offer its enrollees at least traditional Medicare benefits, which now will include CCM. It seems reasonable to assume that an MA plan will pay for CCM just as it now pays for other physician services. Whether commercial payers will pay for CCM remains to be seen, although the fact that CMS is paying for this service makes it more likely.

We are still unsure about how to effectively "sell" the $8.00 coinsurance to patients who question why they aren't already receiving that level of care coordination.

Our outreach program is unmatched we have dedicated scripts and value statements to help the chronically ill Medicare beneficiary understand the value and benefit to them as a patient who needs support and guidance to assist them in managing their health. After the consent form has been received by our clinical care managers (RNs) carefully track and monitor the patients, guaranteeing the most effective coordination of care with external providers and agencies. We also provide better access to care for the patients and facilitate scheduling and transportation to their in-office appointments.

Are there specific documentation requirements for the 20 minutes of non-face-to-face services?

The CCM regulations do not require a specific type of documentation of the 20 minutes of non-face-to-face services, nor has CMS issues any guidance on this issue. In the event a provider’s records were to be audited, having the start and stop time recorded for each service would provide the best defense to any challenge.  However, having the start and stop times for some services but not others would likely lead to additional inquiries from the auditors.  For this reason, the better practice is to document (1) the total amount of time spent, (2) the identity of the person providing the service, and (3) a brief description of the service rendered.  Again, CMS has not specifically required this level of documentation; this is instead a best practice to protect an organization in the event of any audit.

We have some of our patients enrolled, billed, and paid. However, patient engagement remains a challenge and we don’ have the resources to manage the remaining patient load for all of our qualifying CCM patients, can you help?

Yes, there is no practice too big or too small, we work with all providers and all patient populations, we understand the true intent and spirit of CMS and we want to bring value to as many providers and patients as possible. We and our Clinical Care Managers are enthusiastic endorsers of the CCM program.

Can the time spent and documented by home health be counted toward the 20 minutes per month?

If this time is part of an otherwise billable home health service, it cannot be applied or counted toward the 20 minute requirement. CMS would characterize this as “double-dipping.”

If you provide more than 20 minutes of non-face-to-face care during the month, can you bill for the extra time in the month that follows?

CMS requires participating providers who bill CPT 99490 to deliver at least 20 minutes of non-face- to- face care to Medicare beneficiaries enrolled in CCM during a given month, this can however take up to 40 minutes per month and the full scope of services must be met. Services must be delivered during that billing month and cannot be applied to future program months.

If 60 minutes or more of clinical staff time are billed per calendar month

CPT Code 99487 can be billed if 60 minutes of clinical staff time directed by a physician or qualified health care professional, per calendar month

CPT Code 99489 can be billed for each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

Is a Certified Medical Assistant qualified to do the assessment or re-assessment required by CMS to bill for this CPT code?

No, only RNs can provide these services to your patients if not completed by a physician or mid-level. If you read and understand the full scope of services needed to provide CCM services to patients on a monthly basis an MA or an LPN does not qualify to fully provide these services. They cannot assess or reassess the patient in order to offer the appropriate guidance and support to the CCM patients. By selecting MAs or LPNs you are ultimately placing more work back on the practice and not being compliant under law for using the proper licensed clinical staff  to put together the comprehensive care plan required in order to begin billing for CCM services.   Additionally, you can be placing your patients at risk.  CMS refers you to the CPT definition of “clinical staff”. Clinical staff is defined as a person who, under the supervision of a practitioner, is allowed by law, regulation, or facility policy to perform or assist in the performance of a specified action and holds licensure in the state where providing services.

It is important if you decide to work with a care management services firm to understand the staff they will be using to perform CCM services.  Some firms are using CNAs, MAs and LPNs to provide the care planning services.  If you are to be audited you would fail if the audit trail was reviewed since these individuals are not legally allowed to provide care planning services, access or reaccess a patient which is part of the scope of services for CCM.

Does non face-to-face care need to be delivered "outside of the office"?

Non-face-to-face care management services may be furnished inside or outside of the provider’s office. Clinical staff must perform these services under the general supervision of a physician. Which is why providers and healthcare organizations can work with care management services firms like our to provide these comprehensive services to their patients as an extension of their practice.

Is a Medical Assistant or Certified Medical Assistant allowed to provide CCM services on behalf of and under the supervision of the doctor and does this time count toward the 20 minutes of time?

Please check the CPT handbook according to what is considered licensed clinical staff for your state.

In 2016, the attorney for the American Association of Medical Assistants (AAMA) stated MAs are only considered licensed “clinical staff” in South Dakota to provide a portion of the CCM services under their licensure. However, under their licensure they are unable to put the comprehensive care plan together, access or reaccess the patient.  Therefore, in every other state medical assistants are not considered licensed clinical staff and cannot provide CCM services.  This was further supported by two other healthcare law firms.  One of the law firms specialized in Medicare audits.  If you need further detail please feel free to call us and we can refer you to the proper attorneys to confirm what we already had 3 expert opinions to confirm.

Can RHCs, CHCs and FQHCs receive reimbursement for the 99490 Chronic Care Management CPT Code?

Yes. Beginning on January 1, 2016, RHCs and FQHCs may receive payment for CCM services furnished to Medicare beneficiaries having multiple (two or more) chronic conditions that are expected to last at least 12 months or until the death of the patient, and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

What is the reimbursement for the 99490 CPT Code for RHCs, CHCs and FQHCs?

The 2017 rate for CCM services in RHCs and FQHCs is $43. The rate is available using the PFS Lookup tool here.

Is the coinsurance/deductible waived for CCM services billed by a RHC, CHC or FQHC?

No. The coinsurance/deductible applies to CCM services.

Can RHCs, FQHCs, and CHCs work with a Care Management Services Vendor to provide these services to their patients?

In CY 2017, RHCs, FQHCs, and CHCs can work with a Care Management Services Vendor to provide these services to their patients under general supervision.

In CY 2016, direct supervision requires that the clinical staff perform these non-face- to-face time services under the umbrella of the RHCs, CHCs and FQHCs and within one of their facilities where they would have access to the billing practitioner.