Medicare has made many changes to billing and coding for chronic care management (CCM) services in 2017 to improve payment accuracy. There are several opportunities to enhance reimbursement for certain CCM services that were not billable earlier and an experienced physician coding company can help with this. Here is an overview of new/revised codes and billing rules for CCM services.
- CPT code changes: Regular (“non-complex”) CCM (CPT 99490) covers chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month. In 2017, Medicare has extended payment to two complex CCM codes, CPT 99487 and 99489.
- 99487: Complex chronic care management services: 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.
- 99489: Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (to be listed separately in addition to code for primary procedure).
Both complex and non-complex chronic care management services cannot be billed simultaneously. For each calendar month, a beneficiary should be classified as eligible either service.
- Date of service on the physician claim and time of claim submission: For CPT 99490, the service period for is one calendar month, and the billing physician/practitioner is expected to continue furnishing services during a given month as medically necessary after the 20 minute time threshold to bill the service is met. When the time threshold to bill is met, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month. In the case of CPT 99487 and 99489, the service code(s) at the end of the service period should be reported, since in addition to specified clinical staff service time, these codes include moderate or high complexity medical decision-making (based on the conditions addressed by the reporting practitioner during the month).
- Revisions to service elements:
- Initiating visit: Only new patients or patients not seen within 1 year prior are required to have an initiating visit for CCM services.
- 24/7 access to care and continuity of care: 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.
- Comprehensive care plan – Providers may choose the format (written or electronic) in which the care plan is provided to patients.
- Management of care transitions documentation: The document will be referred to as a continuity of care document instead of a clinical summary, and formatting of the document and how it is transmitted to other providers is no longer regulated.
- Home and community-based care coordination: Communications must be documented in the patient’s medical record; the earlier requirement to document them in a qualifying certified electronic health record has been removed.
- Beneficiary consent: Provided it is documented in the medical record, the physician can choose to obtain either verbal or written consent.
- New add-on G-code G0506: This code extends payment for CCM initiating visits for patients requiring CCM services including extensive face-to-face assessment and care planning by the physician or other qualified health care professional. This code does not require a modifier and can be billed separately from the monthly care management service c G0506 can only be billed once per patient per provider.
Opting for the services provided by outsourced medical billing companies is a feasible option when it comes to dealing with such extensive coding and billing changes. The teams in these companies stay up-to-date with the latest rules and guidelines and can help providers maximize reimbursement for CCM services.
Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.