Looming Changes to Chronic Care Management

Providers are increasingly using chronic care management (CCM) codes to address care fragmentation issues for patients with multiple chronic conditions. However, until last year, only patients who had two or more chronic conditions requiring off-site management qualified for extra care management services and physician reimbursement.

For 2022, the Centers for Medicare & Medicaid Services (CMS) has added four new codes for principal care management (PCM), allowing for “extra reimbursement” to providers managing patients who have one complex chronic condition that requires management by a specialist.

The additional reimbursement of approximately $52 monthly for PCM services could either encourage providers to adopt PCM or create some unaddressed challenges of staffing and implementation, if the cost outweighs the administrative burden. However, reimbursement for activities that clinicians are already performing should be evaluated, to make a best-practices decision on both PCM and CCM in your practices.

Let’s first address what most physicians and practices have heard of – and that is chronic care management services.

Chronic Care Management

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. Furthermore, these chronic conditions “place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,” per CPT® Professional Edition 2021, page 65. This is an important distinction, so do not necessarily enroll all patients with two or more chronic conditions into these management services. Clean claims follow the rules to the letter.

CMS recognizes that CCM services are critical components of patient care that promote better health and reduce overall healthcare costs. However, it is important to note that these services have specific rules and guidelines that must be followed to support reimbursement.

Professionals Who May Furnish and Bill CCM Services

Only one physician or other qualified healthcare professional who assumes the care management role for a beneficiary can bill for providing CCM services to that patient in a given calendar month. While services may be provided by a clinical staff person, the service must be billed under the supervision of a QHP (qualified healthcare professional) who is one of the following:

• Physician (MD/DO);
• Clinical nurse specialist (CNS);
• Nurse practitioner (NP);
• Physician assistant (PA); or
• Certified nurse midwife.

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

Also, many providers and medical practices subcontract with third-party companies to facilitate their care management services, but be cautioned on that. If the clinical staff employed by the case management company are located internationally, there is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9). CCM services cannot be billed if they are provided in such a fashion.

There has been some non-compliance on this issue alone.

The five CPT® codes used to report CCM services are:

• CPT code 99490: non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability;
• CPT code 99439: each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified healthcare professional (billed in conjunction with CPT code 99490);
• CPT code 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;
• CPT code 99489: is each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualified healthcare professional (report in conjunction with CPT code 99487; cannot be billed with CPT code 99490); and
• CPT code 99491: CCM services provided personally by a physician or other qualified healthcare professional for at least 30 minutes.

Requirements and Components for CCM and Complex CCM

Principal Care Management (PCM) Services – CPT codes in 2022

In 2020, CMS approved two HCPCS codes for what they call “principal care management.” These codes, G2064 and G2065, like other chronic care management codes, were intended to reimburse physicians for the additional work they do caring for high-risk, complex patients. This includes the extra time and work required for medication adjustments, creating a care plan, patient follow-up, and more. These codes will be replaced in 2022 with four new CPT® codes:

• 99424 and 99425 are for time spent by a physician or other qualified healthcare professional (someone with evaluation and management, E&M, in their scope of practice) and 99426 and 99427 are for clinical staff time directed by a physician or other qualified healthcare professional.
• These are time-based codes used for managing a patient with a single, complex chronic condition.

A good example of when this could be used would be an allergist treating a patient with uncontrolled asthma. The new codes can provider additional monthly payments, above existing in-person E&M office visit codes. These patients who have high-risk asthma could meet the required criteria for these services, as they are complicated patients, and the goal is to keep them out of the ER and hospital if they have flare-ups. This option could lessen those episodes of exacerbation with continued non-face-to-face management.

Remember that the provider/clinical staff time does not have to be face-to-face time, but can be time used to create care plans, follow up with patients via phone, etc.

Patients covered by PCM codes must meet the following criteria defined by CMS:

• They have one complex chronic condition lasting at least three months;

• The condition places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death;

• The condition is severe enough that the patient is at risk for hospitalization or was recently hospitalized due to the condition;
• The condition requires development or revision of a disease-specific care plan; and
• The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

There are two potential barriers to using PCM codes:

• Patients must consent to receive the service.
• Patients are responsible for the 20-percent beneficiary cost-sharing requirement for CCM services.

However, the Chronic Care Management Improvement Act currently in Congress would eliminate the 20-percent beneficiary cost-sharing requirement for CCM services. If passed, Medicare would then pay 100 percent of the service costs for CCM.

​Specialists using PCM codes are not required to assume complete care of the patient for other, unrelated diagnoses, although co-morbidities should be taken into consideration during treatment.

The requirements for PCM codes are very specific and easily audited. Physicians’ billing PCM codes need to carefully document that patients meet the above criteria. The disease-specific care plan (not a comprehensive care plan) should be included in the patient’s chart, along with documentation of medication adjustments, patient communications, etc.

CMS/Medicare and MA (Medicare Advantage) plans do cover and reimburse for care management services. However, other private payers and Medicaid are not obligated to pay these codes. Providers need to check with the payor or state Medicaid program to verify coverage.

A reminder: the 2022 Professional Edition CPT® defines these services as “principal care management” for patients with a single high-risk disease or complex condition. The existing CCM codes require that a patient have two or more chronic conditions. The qualifying condition for reporting PCM codes would be a patient with one serious chronic condition, typically expected to last at least three months, and includes “establishing, implementing, revising, or monitoring a care plan specific to that single disease.”

Principal care management services of less than 30 minutes’ duration in a calendar month are not reported separately.

Programming Note:

To hear more on this topic and understand the intent of the new 2022 codes, listen to Talk Ten Tuesdays today, when Fletcher will expand on this important topic for physicians and outline compliance standards.