Care Management Services: Get Paid for What you are Already Doing

Defining Medicare’s chronic care management services.

CCM services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. These services are for patients who qualify for ongoing management and surveillance through a care management program.

The Centers for Medicare & Medicaid Services (CMS) recognizes that CCM is a critical component of primary care that promotes better health and reduces overall healthcare costs.

CCM Coding
The four CPT® codes used to report CCM services are the following:

• 99490 Chronic care management services, at least 20 minutes of clinic staff time directed by a physician or other qualified healthcare 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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
• Comprehensive care plan established, implemented, revised, or monitored.
  (CCM services of less than 20 minutes in a calendar month, are not reported separately)

• 99487 Complex CCM is a 60-minute timed service provided by clinical staff to substantially revise or establish a comprehensive care plan that involves moderate to high-complexity medical decision-making (MDM).
• 99489 is each additional 30 minutes (cannot be billed with CPT code 99490)
• 99491 CCM services provided personally by a physician or other qualified healthcare professional for 30 minutes.

Qualifying Patients

• Patients must consent to the service.
• There are copays and deductibles attached to reimbursement.
• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
• Having two chronic conditions that are well-managed does not qualify the patient for CCM.

Requirements and Components for CCM and Complex CCM
CCM services must be documented in the electronic health record (EHR). Covered services include, but are not limited to:

• Management of chronic conditions
• Management of referrals to other providers
• Management of prescriptions
• Ongoing review of patient status
• 24/7 access (not emergent) to a QHP for questions or concerns regarding chronic conditional needs (i.e. forgot to take daily meds and patient panicked, or feeling tense and not sure if it is anxiety or should call 911, etc).

Non-Complex CCM

• Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
• Patient consent (verbal or signed)
• Personalized care plan in a certified EHR, with a copy provided to patient
• 24/7 patient access to a member of the care team for urgent needs
• Enhanced non-face-to-face communication between patient and care team
• Management of care transitions
• At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by physician or other qualified healthcare professional
• CCM services provided by a physician or other qualified healthcare professional requires at least 30 minutes of personal time spent in care management activities

Complex CCM
Shares common required service elements with CCM, but has different requirements for:

• Amount of clinical staff service time provided (at least 60 minutes)
• Complexity of medical decision-making involved (moderate to high complexity)
• Nature of the care planning performed (establishment or substantial revision of a comprehensive care plan)  

Healthcare Professionals Who May Furnish and Bill CCM
Only one health provider who assumes a care management role for a beneficiary can bill for providing CCM services to that patient in a given calendar month. While services are provided by a clinical staff person, the service must be billed under one of the following:

• Physician
• Clinical nurse specialist (CNS)
• Nurse practitioner (NP)
• Physician assistant (PA)
• Certified nurse midwife

Non-physicians must legally be authorized and qualified to provide CCM in the state in which the services are furnished.

Transitional Care Management
Transitional care management (TCM) codes are for a new or established patient whose medical and/or psycho-social problems require moderate or high-complexity MDM during transitions in care from an inpatient hospital setting, partial hospital, observation status, or skilled nursing facility (SNF) to the patient’s community setting (home, rest home, domiciliary, or assisted living).

TCM starts upon the date of discharge and continues for the next 29 days.

The following are the administrative rules that are mandatory to bill for TCM services under codes 99495-99496.

99495 Transitional Care Management Services with the following required elements:

• Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge.
• Medical decision-making of at least moderate complexity during the service period.
• Face-to-face visit within 14 calendar days of discharge

99496 Transitional Care Management Services with the following required elements:

• Same as above
• Medical decision-making of high complexity during the service period
• Face-to-face visit within seven calendar days of discharge

The healthcare provider accepts care of the beneficiary post-discharge from the facility setting without a gap and takes responsibility for the beneficiary’s care.

Not every patient will qualify for TCM services. This is a specific patient with issues of moderate to severe problems along with mental limitations.

The dates have to be closely monitored.

Third-party vendors are encouraging random FP physicians to obtain a list from the hospital on all discharged patients to take over their transition into their non-hospital community and bill for TCM. This is a compliance red flag.

CMS Comments
Physicians should not undertake TCM services unless they are capable and willing to assume comprehensive responsibility of a patient’s care during the period of the service.

A final policy must be adopted to pay separately for transitional services of a beneficiary, from care furnished by a treating physician to the care furnished by the patient’s primary physician in the community.

Principal Care Management
For 2020, CMS gifted us with a new program – principal care management (PCM). This service will provide additional care to patients with a single, serious, chronic condition.  

To qualify for PCM, a patient must have a diagnosis expected to last between three months and a year, or until the death of the patient, and the diagnosis led to a recent hospitalization and/or places the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.   

PCM closely mimics CCM requirements, and may not be billed concurrently with CCM, behavioral health integration services, monthly capitated ESRD payments, or during a surgical global period. Like with CCM, a verbal consent is required and must be documented in the patient’s chart. 

A difference is that PCM has a time requirement of 30 minutes per month, versus CCM’s 20-minute requirement. The great benefit of PCM is that it provides management for patients with one chronic illness to help navigate and stabilize the condition, with the possible prevention of an exacerbation or secondary diagnosis.   

• G2064 requires 30 minutes of physician or other qualified healthcare professional contact.
• G2065 requires 30 minutes of clinical staff (nurse, MA, etc) time directed by a physician or other qualified healthcare professional.

CMS believes that PCM services are merited for a situation in which a patient’s condition is severe enough to require care management for a single complex chronic condition beyond what is described by CCM or performed in the primary care setting. 

In most cases, a specialist may be the treating provider until the condition is stabilized and the patient is returned to the primary care provider. If the patient has only one complex condition that is overseen by the primary care provider, then that provider will also be able to bill for PCM.

Check your local MPFS to determine if these services warrant adding to your practice as a revenue opportunity. Many practices are already providing these services without realizing there is separate payment for them, if properly documented.

Programming Note: Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10-10:30 a.m. EST.