Answers to Your Questions About Chronic Care Management

A claim for CCM, using code 99490, may be submitted to Medicare once per month when the requirements of the service are met. Twenty minutes of clinical staff time must be spent in non-face-to-face care management of chronic conditions as outlined in the patient's care plan. Only one unit of 99490 per month may be submitted for each patient, even if the time spent exceeds 20 minutes.

The definition states that “clinical staff” must provide the 20 minutes to qualify. A clinical staff member, as defined by CPT, “is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.” If a physician or other qualified health care professional (e.g., nurse practitioner or physician assistant) supplies the service, that time may also count toward the 20 minutes. Although the CCM code is intended to pay practices for nonphysician time, it is understood that some physicians do deliver non-face-to-face services that fall under the CCM umbrella.

Yes. CMS is requiring that a comprehensive visit, initial preventive physical exam (also known as the Welcome to Medicare visit), or annual wellness visit be performed prior to billing CCM. The CCM service may be initiated during such an encounter, with the discussion and creation of a patient-centered care plan. This CCM can follow in the same month, or in a later month. CCM does not replace regular office visits with the physician.

Code 99490 is for the management of chronic illnesses. Acute care is not covered by this payment. You cannot bill 99490 if you did not provide 20 minutes or more of services related to the patient's chronic conditions.

The place of service should reflect where the majority of the services were rendered. Typically, place of service 11 (office) or 22 (outpatient hospital) would apply.

Examples include phone calls and emails to and from the patient, managing referrals to other providers (does not include faxing), managing prescriptions (pharmacy phone time, counseling the patient, etc.), and talking with caregivers.

Yes. The service can be spread out over the entire month. The 20-minute threshold for a particular patient can include any time that clinical staff members in the practice spend providing CCM services to the the patient.

CMS and CPT simply state that a minimum of 20 minutes of clinical staff time must be recorded to bill 99490. Neither indicates how that time should be recorded nor the minimum units of time that make up that 20 minutes or more. It is probably best to record the actual number of minutes spent and not use a standard amount of time for each instance. If and when an auditor requests a set of notes to support 99490, seeing “five minutes spent” for every element of the CCM service may raise questions.

Yes, this time counts as long as you or your clinical staff are doing the work.

If the phone conversation is between the patient and a clinical staff person in the practice and the conversation addresses management of the patient's chronic conditions, then you may count that time toward the 20-minute threshold required to bill 99490.

Yes. According to CPT, care management includes “ongoing review of patient status, including review of laboratory and other studies not reported as part of an evaluation and management service.”

CMS has not dictated the mechanics of how practices are to document the time spent on CCM. That said, we do not believe that an auditor would accept the template checkbox you describe. An auditor would probably be looking for some record of which clinical staff provided CCM services, on which dates, and for how long. Some EHRs are not set up to capture documentation in this way. A service log spreadsheet may be downloaded from the FPM Toolbox.

No. As long as a full 20 minutes of CCM services are documented within the calendar month, the care plan does not need to be initiated within the first days.

The care plan and transitions of care must be recorded in a certified EHR. This should allow for 24/7 access to the information among authorized staff who are providing the CCM service. This information can then be electronically shared with other providers via any means other than fax. This electronic sharing includes (but is not limited to) secure messaging, encrypted email, and EHR-to-EHR connectivity, where it exists. CMS has not mandated how the information is received, only how it is sent. If the receiving practice transforms the electronic information into a fax, your transmission of the data is still acceptable.

It probably does not. We understand this requirement to mean that patients must be able to reach a live person who is a member of the care team or can connect them to the care team in a timely manner to address their urgent chronic care needs.

Email or portal access may count toward satisfying the requirement that the practice provide enhanced opportunities for the patient and any relevant caregiver to communicate with the physician or other provider regarding the patient's care. However, it seems unlikely to satisfy the requirement that the practice provide 24/7 access to address the patient's urgent chronic care needs unless the email or portal is being constantly monitored for that purpose.

All members of the care team within the practice are expected to have 24/7 access to the EHR. As long as that is the case and the patient has the ability to reach a member of the care team (not necessarily the physician) on a 24/7 basis for urgent chronic care needs, then access to care management is assured. The practice may provide the patient with a written or electronic copy of the care plan.

A call center by itself would not meet the definition of 24/7 access unless it was able to quickly connect the patient with a member of his or her care team to address the patient's urgent chronic care needs.

No, but you do need to provide patients with some means of making timely contact with health care providers in the practice (not necessarily the physician) to address urgent chronic care needs.

Because there is beneficiary cost-sharing involved and the service will typically not be face-to-face, CMS wants to ensure that beneficiaries make a conscious decision to receive the service. Thus, CMS has made this an “opt in” benefit rather than an “opt out” one.

No, CMS absolutely requires a signed beneficiary agreement before providing the service, although we recognize that “prudent” does not necessarily carry that connotation. To be clear, CMS considers it a requirement to get the beneficiary's agreement in writing before initiating CCM services.

CMS says it must be a “practitioner.”

Technically, whichever provider has the agreement signed first is the eligible billing party, assuming the patient has not revoked that agreement to sign the second one. Practically speaking, it is likely that the Medicare Administrative Contractor (MAC) will pay whichever provider bills first for the month in question; if that happens to be the second provider, the first provider may have to file an appeal to get paid. It is unclear at this time if Medicare will hold the beneficiary liable for a second claim even if a signed patient agreement is produced. We suggest you contact your local MAC for verification.

This has not been defined, although one MAC has stated that the rendering provider should be the provider who is in the office when the claim is billed. We would recommend that the rendering provider be identified as the physician who developed the care plan and was named in the CCM consent agreement. If that provider is not in the office or is not overseeing the care plan, then the claim should be submitted under the current supervising provider.

CMS allows physicians, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants to bill for CCM. There is not a specialty-specific restriction. Unfortunately, you will not know another provider is billing CCM for the same patient until one of you receives a denial from Medicare. Producing the patient agreement will be imperative for date verification in this instance.

CCM allows for dedicated staff time to assist with care coordination. While some aspects of CCM may have been delivered prior to this program, the beneficiary who consents to receive CCM services becomes eligible for care that meets Medicare program requirements. A sample letter to patients may be downloaded from the FPM Toolbox.

You can bill a midlevel provider's CCM services incident-to those of a physician as long as all of the incident-to requirements are otherwise met. CCM requires “general” incident-to supervision (i.e., the physician does not have to be on site) as opposed to “direct” supervision (i.e., the physician must be in the office suite).

If a patient does not sign the consent, then you may not bill the service to Medicare.

Probably, unless Medicare is treating you and the other physician as one provider, for instance, because you are both part of a group practice.