CMS Coding Changes for Chronic Care Management Benefits Providers and Patients

Few practices were taking advantage of Medicare reimbursements for certain non-face-to-face tasks already being delivered. CMS tweaked the billing and is offering guidance in implementing programs.

Although 35 million Medicare patients fit the eligibility criteria in 2015, code 99490 was billed for 100,000 of them, about 0.2 percent. Based on the limited uptake that first year, CMS modified billing requirements. | 123RF Stock Photo

Chronic conditions afflict the preponderance of Medicare beneficiaries. Two-thirds have two or more long-standing health problems, and one-third have four or more, according to the Centers for Medicare & Medicaid Services .

While many physician practices provide these patients with non-face-to-face chronic care management (CCM), such as reviewing test results or coordinating with specialists, clinicians may be unaware of specific codes that permit separate payments for these services through Medicare Part B.

In March 2017, CMS announced an initiative to inform health care providers about the benefits of chronic care management services for Medicare beneficiaries. The educational effort, Connected Care, offers guidance in implementing chronic care management programs. Designed by CMS' Office of Minority Health and the Health Resources and Services Administration’s Federal Office of Rural Health Policy , the initiative places special emphasis on racial and ethnic minorities and patients in rural communities.

“These codes are a win for patients and primary care providers,” says Samuel L. “Le” Church, MD, MPH, a solo primary care physician with one midlevel provider in Hiawassee, Georgia, a rural area two hours north of Atlanta. In caring for a predominantly older population, “we certainly have the gamut of chronic diseases” — diabetes, heart disease and hypertension, to name a few — so it’s important to be proactive in preventing chronic conditions from escalating, rather than reactive when they spiral out of control.

CPT code 99490, implemented in January 2015, allows Church and other providers to bill for at least 20 minutes of non-face-to-face clinical staff time a month. Directed by a physician or another qualified professional, care coordination is intended for patients with two or more serious chronic conditions expected to last at least 12 months.

Payment varies by region, and in Church’s area, it amounts to $40.73 monthly for each patient receiving CCM services. His practice has more than 400 such patients, which keeps his staff busy scheduling procedures and specialist visits, and following patient responses to medications. When documented in a patient’s chart, these interactions count toward the billable 20 minutes and help augment the practice’s revenue stream, while reducing emergency room visits and hospitalizations, Church says.

Although 35 million Medicare patients fit the CMS eligibility criteria in 2015, the code was billed for only 100,000 of them, or about 0.2 percent. Many physicians considered the billing and documentation requirements too burdensome, and they opted not to seek reimbursement for the services, says Dennis Weaver, MD, MBA, chief medical officer and executive vice president at Advisory Board, a health care research, consulting and technology firm.

Based on limited uptake and industry feedback, CMS continued to modify billing requirements for the code to make it easier to use. For instance, CMS removed the stipulation for written patient consent before billing for CCM services in favor of documenting verbal consent in the medical record.

As of Jan. 1, 2017, updates also began applying to CPT code 99487 (which pays $88.03 in Church’s region) for complex chronic care management when certain conditions are fulfilled, including 60 minutes of clinical staff time per month. In 2017, CMS added CPT code 99489 ($44.18 for Church) for each additional 30 minutes of staff time in managing complex chronic care. Meanwhile, CMS introduced Healthcare Common Procedure Coding System code G0506 ($60.78 for Church) as an add-on to an initial visit for comprehensive assessment and care planning.

Many physicians wonder whether the efforts to set up a CCM program and maintain proper documentation are worth it, Weaver says, but with the assistance of technology vendors, physician practices can modify their electronic medical records to accommodate the requirements.

In a well-designed system, a practice takes care of a panel of patients’ needs - not only the ones with scheduled appointments. The staff can interact with patients in various ways —phone, email or texts — to support them in taking medications, following dietary and exercise plans, and controlling stress, says Cory B. Sevin, RN, MSN, NP, a director at the Institute for Healthcare Improvement, an independent not-for-profit organization.

“Any additional financial incentives that allow a practice to do those sorts of things are very, very helpful,” she says.

Those incentives dovetail nicely with the Chronic Care Model, which Sevin cites as the most evidence-based approach to improving outcomes for patients with chronic conditions.

Barbara Hays, CPC, a coding and compliance strategist at the American Academy of Family Physicians, says it simply “allows physicians and staff to be paid for services that they were already delivering.” Consisting of a team approach, “chronic care management is paving the way for reimbursement under value-based care,” as physicians monitor patients’ illnesses and help avoid unnecessary hospitalization.

Susan Kreimer is a freelance health care writer based in New York.