Chronic Care Management Coding Guidelines Effective January 1, 2017

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Chronic Care Management Coding Guidelines

New Chronic Care Management (CCM) Coding Guidelines Effective January 1, 2017

The Centers for Medicare and Medicaid Services (CMS) recently released new billing requirements for chronic care management services or CCM.

Less than two years ago, on January 1, 2015, Medicare began issuing a separate payment for CCM services under CPT code 99490. This included 20 minutes of non-face-to-face care coordination for Medicare patients with two or more chronic health conditions. However, CMS began receiving feedback from providers that the service elements and billing requirements were too complex and redundant as well as complaints that the code isn’t utilized frequently because it is underpaid compared to the resources spent.

CMS initiated these latest billing changes in order to improve payment accuracy for CCM services as well as reduce administrative burden for providers.

Here are the three of the major changes regarding chronic care management billing that will take effect on January 1, 2017.

1. Better Utilization of Other CCM CPT codes

Before we look at the other CCM codes, let’s review the code description for CPT 99490.

CPT 99490 — 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

As part of the changes taking effect in 2017, CMS has pledged to “appropriately recognize and pay for” other complex chronic care management CPT codes including CPT 99487 and CPT 99489.

The complex CCM code descriptions are as follows:

CPT 99487 — Complex chronic care management services, 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;
  • Establishment or substantial revision of a comprehensive care plan;
  • Moderate or high complexity medical decision-making;
  • 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

CPT 99489 — 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).

During each calendar month, if you have accumulated less than 60 minutes of clinical staff time, then CPT 99487 should not be billed separately. Likewise, if less than 30 minutes have accumulated in addition to the first 60 minutes of complex CCM, then CPT 99489 should not be billed separately.

Frequency of Reporting — CPT codes 99487, 99489, and 99490 may only be reported once per calendar month and only by the practitioner who provided care management during that calendar month. Only one professional claim should be submitted per calendar month.

Complex VS Non-Complex — For each calendar month, a beneficiary should be classified as eligible either for complex or non-complex chronic care management. Both types of services cannot be billed simultaneously.

2. Service Element Revisions

CMS also proposed changes to the required service elements that need to be met in order to bill for any chronic care management service. Specifically, revisions were made to six service elements including:

  • Initiating visit
  • 24/7 access to care and continuity of care
  • Comprehensive care plan
  • Management of care transitions documentation
  • Home and community-based care coordination
  • Beneficiary consent

The changes to these six service elements as well as the complete list of service elements for 2017 are listed below. Remember, the proposed service elements must be met in order to bill for any of the three CCM codes — CPT 99487, 99489, and 99490.

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Service Elements

Initiating Visit

Current Rule: To enroll patients in CCM services, the billing physician must have a face-to-face Level 2-5 E/M visit, an Annual Wellness Visit (AWV), or an initial “Welcome to Medicare” (also called an initial preventive physician examination or IPPE) visit with the patient.

New Rule: Only new patients or patients not seen within 1 year prior are required to have an initiating visit for CCM services. The initiating face-to-face visit is no longer required for existing patients who have been seen within the past year. A new CPT code G0506 should also be billed in conjunction with the start or initiation of CCM services. Look for more details on this code below.

  • Initiation during an Annual Wellness Visit (AWV), Welcome to Medicare/initial preventive physician examination (IPPE), or face-to-face E/M visit (Level 4 or 5 visit not required), for new patients or patients not seen within 1 year prior to the commencement of chronic care management (CCM) services.

Structured Recording of Patient Information Using Certified EHR Technology

  • Structured recording of demographics, problems, medications and medication allergies using certified EHR technology.
  • A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care.

24/7 Access & Continuity of Care

24-7 Chronic Care Management AccessCurrent Rule: Ensure 24-hour-a-day, 7-day-a-week (24/7) access to care management services, providing the patient with a means to make timely contact with healthcare practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs.

New Rule: The requirement regarding after-hours access to the beneficiary’s electronic care plan has been eliminated. CMS will allow fax to count for electronic transmission of clinical summaries and the care plan.

  • Provide 24/7 access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with healthcare professionals in the practice to address urgent needs regardless of the time of day or day of week.
  • Continuity of care with a designated member of the care team with whom the beneficiary is able to schedule successive routine appointments.

Comprehensive Care Management

  • Care management for chronic conditions including systematic assessment of the beneficiary’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of beneficiary self-management of medications.

Comprehensive Care Plan

Current Rule: The beneficiary must be provided with a written or electronic copy of the care plan.

New Rule: Providers may choose the format in which the care plan is provided to patients.

  • Creation, revision and/or monitoring (as per code descriptors) of an electronic patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues.
  • Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the beneficiary’s care.
  • A copy of the plan of care must be given to the patient and/or caregiver.

Management of Care Transitions

CCM Comprehensive Care PlanCurrent Rule: The physician must create a clinical summary and transmit it to other providers involved in the beneficiary’s care to ensure continuity of care. Clinical summaries should be formatted according to CCM certified technology and transmitted electronically (other than fax).

New Rule: The document will now be referred to as a continuity of care document instead of a clinical summary. Formatting of the document as well as how it is transmitted to other providers is no longer regulated.

  • Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
  • Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers.

Home- and Community-Based Care Coordination

Current Rule: A physician must document (in a qualifying certified electronic health record) communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits.

New Rule: Those communications must be documented in the patient’s medical record, but the requirement to do so in a qualifying certified electronic health record has been removed.

  • Coordination with home and community-based clinical service providers.
  • Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record.

Enhanced Communication Opportunities

  • Enhanced opportunities for the beneficiary and any caregiver to communicate with the practitioner regarding the beneficiary’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods.

Beneficiary Consent

Current Rule: Written consent must be obtained from the beneficiary.

New Rule: The provider can choose to obtain either verbal or written consent, provided it is documented in the medical record.

  • Inform the beneficiary of the availability of CCM services; that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month).
  • Document in the beneficiary’s medical record that the required information was explained and whether the beneficiary accepted or declined the services.

Medical Decision-Making

  • Complex CCM services require and include medical decision-making of moderate to high complexity (by the physician or other billing practitioner).

3. New Add-on G-code

CMS also created a new add-on G-code to “improve payment for services that qualify as initiating visits for CCM services.”

CPT G0506 — Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services (billed separately from monthly care management services) (Add-on code, list separately in addition to primary service).

This code is to be billed for beneficiaries requiring extensive face-to-face assessment and face-to-face or non-face-to-face care planning. For this code, the assessment and planning is conducted by the physician instead of the clinical staff as is the case for CPT codes 99487, 99489, and 99490.

In addition to billing for the initiating visit (which could be an E/M, AWV, or IPPE), the physician should also bill CPT G0506 for the comprehensive assessment and planning.

G0506 may only be billed once per beneficiary, in conjunction with the start or initiation of CCM services. CPT codes 99487, 99489, and 99490 may be billed with G0506, assuming the billing requirements are met.

Note regarding behavioral health: Code G0505 and G0506 may not be billed the same day by the same practitioner.

G0505 — Cognition and functional assessment by the physician or other qualified health care professional in office or other outpatient, prolonged non-face-to-face services

Other Billing Changes

The final rule will be published in the Federal Register on November 15, 2016. In it, there will be several other billing and coding changes set to take effect January 1, 2017. According to CMS, these changes will help to “better identify and value primary care, care management, and cognitive services.”

  • Below are some of the additional changes you can expect to see in the final ruling: Make Federal Register November 15, 2016separate payments using a new code to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia).
  • Make separate payments using new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions. Several of these codes describe services within behavioral health integration models of care, including the Psychiatric Collaborative Care Model that involves care coordination between a psychiatric consultant or behavioral health specialist, behavioral health care manager, and the primary care clinician, which has been shown to improve quality of care.

Expected Chronic Care Reimbursement Rates

It’s worth noting the estimated payments you can expect from Medicare when billing for chronic care management services. Here is a quick checklist to keep handy for future reference. Check with your local Medicare carrier for exact rates in your area.

CODE DESCRIPTION FEE
99490 Chronic care management services $42
99487 Complex chronic care management services $88
99489  Each additional 30 minutes $44
G0505 Cognition and functional assessment $227
G0506 Comprehensive assessment and care planning $61

 

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What do you think about the new CCM guidelines? What questions or concerns do you have? Please join the conversation below.

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17 Responses to “Chronic Care Management Coding Guidelines Effective January 1, 2017”

  1. Hi Manny, thanks for the quality information. May I ask you which HMO’s don’t reimburse for CCM?

    Reply
  2. Great information!
    We are ready to provide CCM. We are located in a large vacation community. Is there anyway/anywhere to know if a patient is enrolled elsewhere?

    Reply
  3. I am getting denial from Medicare for G0506 stating that this is not paid separately even we have resubmitted with code 99490

    Can you please let me know which primary code should I bill with G0506 or any modifier to be billed to get payment from Medicare

    Thanks

    Reply
  4. I am getting denial from Medicare for G0506 stating that this is not paid separately even we have resubmitted with code 9990

    Can you please let me know which primary code should I bill with G0506 or any modifier to be billed to get payment from Medicare

    Thanks

    Reply
  5. Manny,
    We are now much more into using these codes. My question concerns the usage of G0505 used for the Cognitive Assessment.
    1. How many times can this code be used in the lifetime of the patient.
    2. Can it be used in conjunction with any other codes?
    3. Can it be used the same month as CCM codes are used?
    Thanks,
    R.Muhammad, D.O.

    Reply
    • 1. How many times can G0505 be used in the lifetime of the patient? Currently, the code looks like it has no restrictions on how many times G0505 can be done.

      2. Can G0505 be used in conjunction with any other codes? G0505 can’t be billed with services such as E/M codes, advanced planning services, and some other psych codes as some elements of the services overlap. Here is a list of the services G0505 cannot be used with: 90785, 90791, 90792, 92610, 96103, 96120, 96127, 99201-99215, 99324-99337, 99341-99350, 99366-99368, 99497, 99498, 99374, G0181, G0182 and GPPP7.

      3. Can it be used the same month as CCM codes are used?
      Yes, G0505 can be billed with CCM codes, 99487, 99489 and 99490. It can also be billed with Transitional Care Management (TCM) codes 99495 and 99496.

      Contact your local Medicare Administrative Contractor (MAC) for their billing policies on G0505.

      Hope this helps.

      Reply
  6. cms denied more than one unit of 99489 – is there a max for this add on code? can we bill if more than additional 30 mins done?

    Reply
  7. Hi Is G0506 only for new patients to a practice or can it be billed for existing patients with a 99213 or 99214 or 99215?
    Thanks!

    Reply
  8. I am getting denial from Medicare for G0506 stating this should be billed along with primary code. we billed 99490 along with G0506 however it got denied for the same reason, can you please let me know which primary code should I bill with G0506? Thanks

    Reply
  9. Hi Manny,

    I just want to be sure but can we bill an E/M code with a Chronic Care if it’s unrelated with a 25 modifier?

    Reply
  10. Hi,

    Are the chronic care codes only covered by CMS? We have received denials from Anthem, so are wondering if that is why.

    Reply
  11. Thank you for your CCM article. We began billing for CCM Feb 2017 and are having trouble getting paid for G0506 when used with an ACLF E&M code (99336, 99327, etc) accompanied by a 25 modifier. No issues when billing in office setting with 99213, 99214, etc. Any advice? Note from Biller copied below.

    As per EOB under payment batch the CPT G0506 was denied by MEDICARE B-FL: FIRST COAST SERVICE OPTIONS [16040] on 04/14/2017 stating This service/procedure requires that a qualifying service/procedure be received and covered. Per conversation with the Medicare rep CPT G0506 requires to be billed with a primary G- code. *Please update appropriate Primary CPT.

    Reply
  12. Hey Manny. It’s so nice to have some1 that’s on top of current updates. : )
    I really appreciate Everything you do & all the information you unselfishly disseminate to your peers. : )

    I do have a general question for you. Have you heard about a NEW “Rural Billing” and NEW Modifiers GS or something like that?

    Thanks,
    Sara
    [email protected]

    Reply
  13. Good Morning Manny,
    We are having success billing the G0506 with the E&M CPT coded with modifier 25 but if we bill G0506 with AWV( GO438 or G0439) or IPE (G0402) it is being denied. Should we be adding modifier 33 to G0506 when we bill with G0438, G0439, or G0402?

    Thank you

    Reply
  14. Thank you for all the informative articles. I am a new subscriber and really appreciate the information and the way that you explain things. I look forward to more reading. It is refreshing to see the way you care about what you do. I strive for excellence everyday and love what I do. Sometimes, I don’t see that from others. Thank you again for thinking of others and sharing so much information!!

    Reply
    • Thank you Susan for your kind words. Much appreciated and welcome to our community.

      Reply
  15. This is some very welcome news. We have more than a few patients who have become acutely aware that they can access us anytime for phone conversations. Many go way over the 20 minutes suggested in the roll out. Now, we can actually bill for time as spent with these types of patients. With several in particular we easily go over an hour of time in a month coordinating services, medications, answering questions, reviewing labs, consults and studies. I finally feel like they actually want me to stay in practice especially after the 0.5% penalty we now suffer from.

    By the way, if it were not for this article being posted by this site I don’t know when we may have heard anything about this. You are much appreciated and we are also now looking really hard at our current billing partner as they know NOTHING about this. You obviously have a passion for what you do.

    Reply
    • Thank you Dr. Muhammad for your kind words. I think what sets us apart from other billing companies is that we started as a medical practice and still have that practice. So we know what doctors go through each and every day because we have the same struggles too. You could say we do conscious medical billing because we care and try to help your practice not just process your paperwork. Thanks again.

      Reply
  16. Absolutely value your articles. I would love to use your information as training topics but unfortunately, I see no way to print the articles. Can you add an option to download as a PDF?

    Reply
    • Oops, I forgot. We usually put a button at the end. Check back in an hour or so while we put one together for you and our other readers.

      Reply
        • Thanks Manny.
          This is awesome information.

          BTW, I always look forward to your emails because I KNOW I’m gonna get pertinent/useful information.

          As always, thanks for All you do.
          I sure appreciate you. : )

          Sara De La Cruz
          Patient Services Representative
          [email protected]
          Jennie Stuart Medical Group
          Hopkinsville, KY

          Reply

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