Chronic Care Management: new CPT and CMS benefit code for 2015


In the 2015 Final Physician Fee Schedule released on Halloween (CMS loves holiday releases of rules) CMS continues to state its support for primary care. One of the methods: a new benefit, chronic care management (CCM) for which they are proposing a rate of about $40 for 20 minutes or more of this non-face-to-face service during a calendar month. We knew about this from the proposed rule but were in wait and see mode until the final rule came out.

Here’s a surprise! CMS is going to use a CPT code instead of developing a HCPCS code to describe the service. In the proposed rule they stated their intention of developing a HCPCS code but they’ve changed their minds. This means that practices can learn about this code right in a resource that is sitting on their shelves. I hope everyone reading this has their 2015 CPT code on the desk right now.

The new CPT code is 99490: chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following elements:
• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
• chronic conditions placed the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
• comprehensive Care plan established, implemented, revised, or monitored.

There is an additional editorial note stating “chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately.”

CMS will not use the CPT codes for complex chronic care coordination services 99487—99489. Those will continue to have a bundled status indicator.

In order to be eligible the patient must have two or more significant chronic problems, expected to last at least 12 months or be life long conditions. They must be the type of conditions that pose a real risk to the patient’s health and well-being. The practice must implement a care plan that addresses the patient’s conditions and a clinical staff member must spend 20 minutes during a calendar coordinating care and communicating with the patient. The practice must use a certified EHR. The physician develops a care plan, and everyone who has contact with the patient must have access to the electronic care plan. A copy of the care plan is provided to the patient, electronically or on paper. The electronic record must include a full list of problems and medications and should facilitate caring for the patient during care transitions. Medication reconciliation is required as part of the service. The patient must have access to the practice 24 hours a day, 7 days a week. One provider must be designated for continuity of care. Care management includes assessment of the patient’s medical, functional and psychosocial needs.The practice must create a patient-centered care plan, manage care transitions, and coordinate with home and community services.

Informed consent is required before starting the service. The practice must inform the patient that they will provide this service and get written consent from the patient to do so and to share information with other providers. The practice must also inform that patient that they can revoke this consent and stop receiving CCM services at any time. Document these communications in the record, and give the patient a written or electronic copy of the care plan. The co-pay and deductible are not waived for this service, but will be patient due.

CMS is proposing general, not direct, supervision of the clinical staff who perform these services. Nursing staff after hours or during normal business hours may perform these coordination services even if the physician or billing NPP is not in the office

It looks like a lot of work to me for $40.00. The practice may only report this service during the month in which the clinical staff has 20 minutes of non-face-to-face time with the patient. If the practice is already providing these services as part of a patient centered medical home, the service will be easier to provide and may not represent significant additional cost. The payment may support the additional infrastructure needed to manage the care of these patients.

If you have your 2015 copy of the CPT book—and, again, I hope you do– you can read for yourself in more detail what the billing rules are. I am summarizing these but it is no substitute for reading them yourself. First, both CPT and CMS state that clinical staff should be doing the work. Also, a practice may not count any clinical staff time on a day when the physician or qualified healthcare professional (NP/PA) has an evaluation and management service with the patient. However, E/M services may be reported during the same calendar month the chronic care management is provided. There is a list of services in the CPT book that are bundled into chronic care management. These include care plan oversight and transitional care management, amongst other codes. The surgeon may not perform chronic care management during the postop period.

If your practice is already a patient centered medical home or you are already providing case management for a group of chronically ill patients, you are ready to begin performing chronic care management. However, if you are not already providing the services it is unlikely that you will be able to do these starting January 1. It requires an infrastructure within the practice to provide the services. Also, you will need to have an evaluation and management service with the patient to explain the service, sign the informed consent, and develop the care plan. This calls for gradually rolling out chronic care management services not immediately reporting them on all patients who will be eligible. Remember this is not a per member per month benefit– just because you provide the service one month does not mean you can provide the service the next month. The clinical staff must spend at least 20 minutes providing these coordination and care management services in order to report them. Most practices don’t have a template or form setup for this. Groups will need to think about how and where this information is being documented before rushing to bill for this service.

By Narath Carlisle, MD, MPH

20 thoughts on “Chronic Care Management: new CPT and CMS benefit code for 2015

  1. Thanks Betsy- good synopsis. Our major revenue concern about billing CCM services is whether we will regret loosing TCM revenue. Has CMS clarified whether during a month where a patient is hospitalized, can we just not bill the CCM charge that month and instead bill the TCM code?

    • Yes, CPT clarified it. “…transitional care management (99495 and 99496) … and if performed, these services may not be reported separately during the month for which 99490” is reported. It is part of a long sentence that lists a dozen other services that may not be billed on the same day. If you can get ahold of the 2015 CPT book you’ll see them all. Many are bundled anyway, and we don’t bill them. But care plan oversight and TCM may not be billed “during the month for which” CCM is reported.

  2. ” The physician develops a care plan, and everyone who has contact with the patient must have access to the electronic care plan”
    This requirement seems difficult, especially if the patient is seeing home health nurses or lives at an Assisted care living facility. Handing out limited access EMR ID’s and passwords, training, confidentiality agreements with a bunch of health care aids & nurses who aren’t part of the practice doesn’t seem easily doable.

  3. Thank you for this. I don’t think I was clear in my article. CCM must be furnished with the use of an EHR that includes an electronic care plan that is accessible at all times to “practitioners within the practice, including those furnishing CCM outside of business hours.” “However, the electronic plan would not have to be available at all times to other non-billing practices…” The final rule states, “In addition, practitioners must electronically share care plan information as appropriate with other provides and practitioners who are furnishing care to the patient. We are not requiring that practitioners use a specific electronic technology to meet the requirement for 24/7 access to the care plan or its transmission, only that they use an electronic technology other than facsimile. For instance, practices may satisfy the 24/7 care plan access requirement through remote access to the EHR, web based access to a care management application, or web-based access to a health information exchange service that captures and maintains care plan information.” They may meet this requirement through the use of “secure messaging or participation in a health information exchange with those practices and providers, although they may not use facsimile transmission.”

  4. Education for diabetic patients is important and should be part of the care plan. Some education materials once prepared can be reused for many patients, but it takes time to prepare materials. How much, if any, of this time can be counted toward the 20 minutes spent with the patient in a given month? Can time time spend modifying or assembling materials for the patient count toward the 20 minutes spent with the patient?

    • The guidelines aren’t this specific. But, the CPT book includes “patient and/or family/caregiver education to support self-management, independent living and the activities of daily living.” As I read that, I would not include time spent in organizing or preparing educational materials, only in providing the education.

    • Also, there are two other codes Revenue code 0590 for home health visit (in case there is a need for home health visit) and s9110.. can they go together?

      • We are trying to provide a outsourced CCM service and have spoken to some physicians and home health agencies that we would like partner and refer patients to us for CCM services. The physicians and home health agencies would like us to provide all 24/7 clinical triage plus technology while they bill AWV, get consent and pass on the patient to us for ongoing monitoring whilst they bill for them monthly and share a part of the $42 with us. The home health agents are confused if they can still provide home health visit in the month that the physician bills (we provide service but the doc bills for it) for CCM and the physicians would also like us to get physiologic vital sign information of the patient to know more about the patient’s condition and enhance satisfaction. As you well know, the vital devices cost money along with the internet costs and smartphones to transmit them not speak of device replacement and repairs {{expecting most of the patients to not have internet or smartphone in their home}}.. so we were looking at alternative codes that can be tagged along to enhance the reimbursements to cover for vital monitoring. Any info you could provide on any other codes like S9110 or 99091 or S9122 that can be tagged along with 99490 (CCM) would be greatly appreciated.

  5. I spent 20 minutes putting together a detailed and comprehensive plan of care for a patient with many medical problems, many medications, many other providers involved with his care, and emailed this comprehensive plan to the patient and kept a copy for my records. I did not call him and have direct contact with him abot this. Can I bill a 99490 for this? Also, on another patient, I spent 20 minutes reviewing the entire medical chart going back 25 years on another patient, updating medical problems, reconciling current medications, etc. I did not contact anyone about this. Can I bill a 99490 for this? Lastly, in terms of chronic care management, I’m starting to see the phrase “contact-initiated”, and wonder where that came from ….the implication is that only a chronic care management service that involves direct contact (Non face to face) with someone….patient, MD, pharmacist, visiting nurse etc counts for a chronic care management service….I don’t think i saw this requirement spelled out in the CMS white paper and wonder where it came from…it adds a significant, onerous burden to the process…..20 minutes of contact (not just management) is a huge hurdle. If you have 120 patients that means to bill for all of them for one month, you need 40 hours per month of contact. I seriously doubt that even our sickest and most complicated patients require 20 minutes of contact over the course of a month on any sort of a consistent basis, and if this is a deal breaker, it hardly seems worth it…it seems unlikely that this “contact”requirement is part of the mandate…please clarify.

    • In order to report CCM you have to see the patient for either an AWV, IPPE or comprehensive E/M, develop the plan of care, get written consent from the patient, and keep a log of the 20 minutes in the calendar month. Only your clinicians and staff may count time for CCM. The pharmacist or VNA time don’t count for YOUR CCM minutes.
      If you or your staff don’t spend 20 minutes in the calendar month, you don’t bill for it.

  6. It would seem that a large, multidisciplinary team that cooperatively manages chronic conditions e.g. patients with diabetic neuroischemic lower extremity ulcers, 99490 would make sense and that it would logically require 99091 in order to encourage and expedite specialist consult when one is dealing with primary care providers located >20 miles from specialty care. However, Medicare is quite restrictive so all of this feels quite impractical to implement for both provider and patient….

  7. Is it true that you cannot bill a 99490 without first “initiating” CCM with either an AWV or a comprehensive E/M visit in that year? The rules keep changing. I meet all the criteria and sent out a detailed explanation to my patients, got their consent, then did 20minutes in January on many of them, only to find out that I cannot bill a 99490 because I did not do an AWV or comprehensive E/M visit this year. The AWV I did in November 2014 doesn’t count, nor does a comprehensive E/M visit in December that did not involve “initiating” CCM. It is hard enough to explain to patients that CMS thinks we should get a management fee for all the non face to face work we do but, “Oh, by the way, you have to pay for some of my management fee.”…..and now this initiating requirement. I mean, do they want us doing chronic care management or this some sort of trap? Very annoying.

    • I would appeal at least one of them, and see what your Contractor does. I would send a copy of the AWV from Nov and the comprehensive visit from Dec and most importantly: your care plan, the time log of the 20 minutes and the written consent.
      Yes, CMS states that in order to bill for the CCM it must be initiated at an AWV, IPPE or comprehensive E/M.

      • thanks for the reply….can you give me a link to the CMS statement that “in order to bill for the CCM it must be initiated at an AWV, IPPE or comprehensive E/M.” I cannot find that in any CMS document.Thanks very much.

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