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Chronic Care Management, Value Based & Billable

Care Coordination 2.0 (Part 1)

CMS care initiative programs are finally rewarding doctors for work they’ve been doing all along, namely Chronic Care Management (CCM), and there’s a renewed interest in care coordination as providers and payers realize its significance in patient outcomes. With chronic care patients benefiting the most—and two-thirds of Medicare patients are shown to have two or more chronic conditions—CMS is  putting its money where its mouth is  and paying providers to deliver coordinated care.

CPT code 99490  allows eligible providers to bill for at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional per calendar month on managing and coordinating care for Medicare and dual-eligible patients with two or more chronic conditions expected to last at least 12 months or until death.

CPT code 99487  is for complex Chronic Care Management that requires establishment or substantial revision of a care plan, moderate or high complexity medical decision making, and 60 minutes of clinical staff time.

CPT code 99489  is an add-on code to complex CCM (CPT 99487) for each additional 30 minutes of clinical staff time.

HCPCS code G0506  is an add-on code to the CCM initiating visit that describes the work of the billing practitioner in a comprehensive assessment and care planning to patients outside of the usual effort described by the initiating visit code

CCM program details
Here are examples of chronic conditions covered by the CMS program; other conditions may also be covered.

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular disease
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS

To bill for CCM, providers must:

  1. Obtain verbal or written agreement from the patient to receive these services. The patient must understand that they’re responsible for applicable cost sharing, that they can stop participating at any time, and that only one provider or hospital can provide CCM in a calendar month.
  2. Create and update an electronic Comprehensive Care Plan that tracks the patient’s health issues. They must share it with the patient or their caregiver when appropriate, periodically review the plan with the patient, and share it with other providers as appropriate.
  3. Provide continuity of care for the patient through a designated care team member with whom the patient can schedule appointments and who is regularly in touch with the patient to help them manage their conditions.
  4. Record certain data through a certified EHR, including the patient’s demographics, medical problems, medications, and medication allergies.
  5. Provide patients with a way to reach the practice at any time to address urgent needs.

CCM services can be billed by:

  • Physicians, PAs, clinical nurse specialists, nurse practitioners, and certified nurse midwives
  • Rural health clinics and federal qualified health centers
  • Hospitals, including critical access hospitals

However, only one provider or hospital can bill for CCM for a patient during a calendar month.
Activities that count toward the minimum monthly service time to bill for CCM include:

  • Comprehensive care management outside of in-person visits, such as by phone or secure email
  • Review of patient records and test results
  • Self-management education and support
  • Coordination and exchange of health information with other practitioners and healthcare professionals
  • Managing care transitions, including referrals and follow-ups for discharged patients
  • Coordinating with home- and community-based clinical service providers and documenting this activity in the patient’s medical record

In our next post, we’ll discuss the benefits to both patients and providers from CCM.

Chronic Conditions Among Medicare Beneficiaries
Chronic Care Management Services Fact Sheet
FAQs About Physician Billing for Chronic Care Management Services

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