Up to half of adult Americans (117 million people) have a chronic medical condition, according to the Centers of Disease Management and Control (CDC). In fact, the majority of patients that family physicians treat and for which medical billing companies help them submit claims, are likely to be 65 or older and Medicare beneficiaries. The American Academy of Family Physicians (AAFP) notes that efficient use of chronic care management (CCM) codes can help providers maximize patient care and reimbursement. With insurers and the Office of Inspector General (OIG) increasing scrutiny of CCM payments, physicians also need to focus on accurate reporting to prevent denials.

Key Components of CCM

The American College of Physicians (ACP) defines Chronic Care Management as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions. CCM is person-centered and contributes to better health outcomes and higher patient satisfaction. This care model requires more centralized management of patient needs and extensive care coordination among practitioners and providers. The key components of CCM services include:

  • Office visits and other face-to-face encounters (billed separately)
  • Communication with the patient and other treating health professionals for care coordination (both electronically and by phone)
  • Medication management and reconciliation
  • Being accessible 24 hours a day to patients as well as other physicians or other clinical staff
  • Creation and revision of electronic care plans by the designated CCM clinician

As only one practitioner can bill for any particular patient, it is important to coordinate with the sub-specialists who may be significantly involved in the care and treatment of one or more of the patient’s conditions. Importantly, family physicians should use the relevant CPT codes appropriately to ensure reimbursable coordinated care management services.

CPT Codes to report CCM Services

Prior to October 1, three CPT codes were available to report CCM services – 99490, 99487 and 99489. In January 2019, CMS will implement another CCM code – 99491.

  • 99490, non-complex CCM services, at least 20 minutes per month
  • 99487 complex CCM, 60-minute timed service provided by clinical staff to substantially review or set up a comprehensive care plan with moderate- to high-complexity medical decision-making
  • 99489 for each additional 30 minutes of staff time, only in conjunction with 99487
  • 99491 Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month.

New CPT Code 99491

The California Medical Association notes: 99491 describes a qualified provider’s time to establish, implement, revise or monitor the care plan for a patient with two or more chronic continuous or episodic health conditions that are expected to last at least 12 months or until the death of the patient; and that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline. The required elements for new CCM code 99491 are:

  • 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

Other CCM codes include:

HCPCS code G0506 – Care Planning for Chronic Care Management

99091 – Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time

Prior to 2018, CMS rules mandated that certain remote care tasks could not be billed for the same patient during the same service period in conjunction with many of the treatments that commonly (and increasingly) utilize remote patient monitoring (RPM) services. In 2018, Medicare/Medicaid CPT code 99091 was unbundled, which means that eligible practitioners can bill to receive separate reimbursement “for time spent on collection and interpretation of health data that is generated by a patient remotely, digitally stored and transmitted to the provider, at a minimum of 30 minutes of time”.

RPM can improve quality of care for patients, maximize efficiency for clinicians, and boost cost effectiveness for payers and providers. The unbundling of 99091 has expanded the scope of Medicare reimbursement for remote treatment.

AAFP Report: Family Physicians Need to Leverage CCM Codes

While CCM codes can help family physicians deliver reimbursable coordinated care for patients with two or more chronic diseases, a recent AAFP report notes that family physicians are not utilizing these codes effectively to bill for important patient services.

A solo family physician, Samuel “Le” Church, M.D., M.P.H., of Hiawassee, GA strongly recommends that family physicians learn to leverage CCM codes. This will help practices to earn additional revenue of up to $1,050 for 25 patients, $2,100 for 50 patients, and $4,200 for 100 patients.

“With CCM, your team can address some needs or quality metrics outside of the precious and limited face-to-face time. If the model is fully embraced, the in-person time can emphasize the ‘caring’ aspect of family medicine and include activities that are most appropriately conducted in the clinic setting”, says Church.

Leading and embracing the comprehensive approach to patient care can improve both care and payments. To achieve this, family physicians need to leverage their team to assist to manage their CCM program, closely coordinate achievement of quality metrics, and adhere to CCM coding rules.

CCM Coding Tips to Prevent Denied Claims

Here are the common reasons for CCM claim denials and the solutions as discussed in a Physicians Practice article published in July 2018:

  • Duplicate billing: This occurs when CCM for the same patient is billed by more than one provider during the same 30-day timeframe, leading to claim denial. This can be avoided by coordinating care with specialists.
  • Billing CCM with other services: Claims will be denied if CCM services are billed with home healthcare supervision/hospice care supervision (HCPCS codes G0181 or G0182), certain end-stage renal disease services (CPT codes 90951-90970), or transitional care management (CPT codes 99495-99496) during the same 30-day period. One solution is to include an edit in the billing software to prevent CCM from being billed with these other services. Another alternative is to hold claims of all CCM patients and manually review them at the end of the month to ensure that the listed services have not been billed.
  • No comprehensive care plan: The provider should document a comprehensive plan of care that addresses all of the patient’s medical needs. Templated language that is not specific to the patient should be avoided. Documentation of care management for chronic conditions should include:
    • A systematic assessment of the patient’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;
    • A patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports.
  • CCM services are not suitable for the patient: The practitioner should clearly specify why the chronic conditions significantly increase the patient’s risk of death or decline. Diagnosis should be reported with the most specific ICD-10 codes.

Medical billing outsourcing to an experienced service provider is the ideal option to maximize payments while preventing denials. With experts handling their billing and CCM coding tasks, physicians can get optimal reimbursement as they focus on their patient’s health.