Getting paid for coordinating care – what does the primary care provider need to do?

by Narath Carlile MD MPH, Betsy Nicoletti

With the 2015 Final Physician Fee Schedule released on Halloween (they seem to love releasing rules on holidays), CMS has introduced non-visit-based payment for chronic care management (CCM). Despite its modest potential rate (0.61 RVUs, or approximately $40 per patient in a calendar month), this structural shift is arguably “the most important broadly applicable change it has made to primary care payment to date.”

We all know that patients with comorbid conditions can’t and don’t get all the care they need in a 30 minute office visit. Finally, physicians can get paid for the coordination work between visits. Here’s how to make it a reality.
What is it?
The new CPT code (99490) allows physicians to bill for 20 or more minutes that their staff spends on non-visit-based care coordination activities each month for their Medicare patients.

So what?
Quality care requires a lot of coordination work between visits, and usually this responsibility falls on the primary care provider. Since coordination is not a visit or procedure, it has not been reimbursed in the past. Many providers, of course, already coordinate their patients’ care because it is the right and necessary thing to do for positive outcomes—however, it comes at a cost to their practice. The new CPT code can help to offset some of that cost. Now, reimbursement is in-line with realistic workflow and quality.

The bottom line: “A physician caring for 200 qualifying patients could see additional revenue of roughly $100,000 annually.”

How is it done?
In order to bill for this code the following conditions must apply to the patient:
● Patient requires at least 20 minutes per calendar month of clinical staff time coordinating care or communicating with the patient (under general—not direct—supervision)
● Patient suffers from 2+ chronic conditions expected to last at least 12 months or until patient’s death
● The chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
Additionally, the practice must meet the following requirements:
● Use a certified EHR (which includes 2011 or 2014 certifications that meet the core technology requirements) (Final Rule page 474)
● Offer 24/7 access to clinicians (who have access to the care plan) to handle urgent care needs
● Maintain a designated practitioner for each patient
● Regarding the care plan:
○ The physician must collaborate with the patient to develop a comprehensive care plan that is accessible to the care team 24/7 — however, this does not have to be created or transmitted by the EHR, and could be fulfilled more effectively by a platform that is designed to create and share a care plan amongst the whole team caring for a patient
○ The electronic care plan should facilitate caring for the patient during transitions
○ Notably, it must be possible to share this care plan digitally with the patient and external providers (including community providers) and the patient needs to have web based access to this as well
● Care management includes assessment of the patient’s medical, functional and psychosocial needs.
And the patient will need to do the following:
● Consent (annually) to you providing CCM services
● Pay the copay for each month you bill for CCM services (approx $8) (of note many patients will have secondary insurance which will cover this)
Really, how is it done?
For many PCMH’s (or practices in the process of becoming one), most of the requirements can be met with the simple addition of an electronic team-based care-planning tool like

Many foresee the major stumbling block being tracking the time spent on between-visit work across multiple team members and easily reporting this so appropriate billing can be done. Some electronic platforms for team-based care coordination like can make this very easy.

Is anyone really taking this on in January?
Yes, and you should take advantage of immediately! We are working with practices who have successfully billed for Transitional Care Management (TCM), and we have identified the tools and processes necessary for practices to address the requirements outlined. We are also starting to test the waters of reimbursement with PCMH’s and ACO’s for all the work they already do.

To claim your coordination reimbursement, we recommend you do these things immediately: First, identify patients that qualify. Second, educate patients and obtain their consent in advance. Third, take another look at your EMR’s functionality to see what it can already do to support this. Fourth, determine how to create a patient-centered care plan based on your usual procedures. Last, identify a way for the entire care team, including the patient and caregiver, to communicate and execute effectively on that care plan.

According to a CMS provider call, RHCs and FQHCs may not report CCM. Also, CCM must be initiated at an AWV, Welcome to Medicare visit or “comprehensive” E/M. The plan may have been developed prior to 2015.

5 thoughts on “Getting paid for coordinating care – what does the primary care provider need to do?

  1. I’m interested in seeing how patients respond, when reviewing the consent, to their copay responsibility ($8/mo, potentially $100/yr). Good observation in your article that those with medigap will have this covered; this will require explanation. To create more incentive for PCP groups to aggressively pursue CCM participation, do you think ACOs might offer to allocate more shared savings to those groups with the most patients enrolled in chronic care management?

    • I don’t have experience with ACOs. I would hope that physicians who care for the sickest patients would not be disadvantaged, economically, in an ACO. But I don’t know the reality.

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