Chronic Care Management – Key Points and Tips

Throughout my many years of servicing physicians as their biller, one common complaint I have heard is about time spent on unbillable services. “My staff and I spend an awful amount of time helping patients over the phone; is there any way I can get paid for that?” Physicians also want to know if they can be paid for services provided in between patient visits, such as completing forms, medication refills, and telephone consults. My response has always been “no”; there was no reliable way to get doctors paid for these types of services. Now however, some of that has changed with Medicare’s new willingness to pay for Chronic Care Management Code 99490.

CPT code 99490 is defined as: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

  1. Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
  2. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
  3. Comprehensive care plan established, implemented, revised, or monitored.

As of January 1st, 2015, Medicare allows a payment of $47.45 for Chronic Care Management. In this blog post, we’ll explore some rules and tips on how to document, and bill for this service.

What is a Chronic Condition?

According to the CDC, 66% of Medicare patients had two or more chronic conditions in 2013. Chronic conditions include:

  • Alzheimer’s and related dementia
  • Arthritis
  • Asthma
  • Atrial Fibrillation
  • Autism
  • Cancer
  • COPD
  • Depression
  • Diabetes
  • Heart Failure
  • Hypertension
  • Ischemic Heart Disease Osteoporosis

Although this is not the complete list, many of the patients my physicians service have two or more of these diseases. So, it’s safe to say many physicians will have a large population of patients eligible for this service.

Key Definitions:

Clinical Staff: a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service; but who does not individually report that professional service. Examples are:

  • Medical Assistants
  • Nurses
  • Therapists

Directed by a Physician: CMS allows a physician to bill for this service so long as the service is provided under his/her general supervision. This means the physician is present and/or accessible during the time of service, and is able to guide the care. No direct contact between the physician and the patient is needed to bill this code.

Comprehensive Care Plan: according to CMS, a Comprehensive Care Plan includes the following:

  1. Problem list;
  2. Expected outcome and prognosis;
  3. Measurable treatment goals;
  4. Symptom management;
  5. Planned interventions and identification of the individuals responsible for each intervention;
  6. Medication management;
  7. Community/social services ordered;
  8. A description of how services of agencies and specialists outside the practice will be directed/coordinated; and
  9. Schedule for periodic review and, when applicable, revision of the care plan.

These items should be documented in the patient’s chart prior to billing for the CCM code.

Key Tips:

1)      Medicare requires that the patient understands and agrees to the chronic care management services before they are offered and billed. It may be best to draft a basic letter that the physician can review with the patient during their face-to-face visit prior to billing for the CCM. This letter should be signed by the patient and recorded in the patient’s record.  This letter should include:

  1. An explanation of the CCM and its availability
  2. An explanation that the patient can revoke the service
  3. A portion explaining that only one provider can bill for this service for each patient
  4. An explanation on what information may be shared between physicians

2)      Medicare requires that an Annual Well Visit or Comprehensive Evaluation and Management code be billed prior to the CCM. During this first visit, document the discussion with the patient described above, his/her acceptance or denial, and the care plan that the CCM will follow.

3)      Chronic Care Management cannot be billed in the same calendar month as a Transition Care Management code (99495-99496), Home Health or Hospice care code (G0181-G0182), or End-Stage Renal Disease service codes (90951-90970). Although the limitation is not explicitly written into the CMS rules, practical billing experience may provide other limitations – such as the inability to bill the CCM during the same calendar month as a comprehensive E/M code or an annual well visit code.

4)      Consider building a template in your EMR/EHR that you or your clinical staff can use to document each CCM service. This template should copy over some elements of the care plan documented during the initial face-to-face visit including: basic demographic information, medication and allergy info, the patient’s consent to the service, and clinical summaries that can be shared with other physicians.

5)      When billing for CCM make the date of service range the calendar month in which you are billing, for example – 01/01/2015-01/31/2015.

Once your letter and EMR templates are set up, documentation and billing of these services should be a breeze. Good luck and happy billing!


Who’s in Control of your Practice?

One of the most interesting things I see when I visit doctor’s offices is that providers are just sick of it.  Sick of the paperwork.  Sick of the back office work.  Sick of prior authorizations.  Sick of employees not pulling their weight.  “Sometimes, I just want to close my office, and go work for someone else”.  I have heard this statement, or a variation of this statement in many of Doctor’s offices I have walked in to.  Nobody sits with a new medical billing company when things are going great, so I’m used to walking into disasters.

The single biggest challenge of having your own practice, is that you are actually running a business now.  You have overhead.  You have to hire and fire employees.  You have to choose vendors.  Pay taxes.  Figure out why patients are cancelling their appointments.  Make sure everyone gets paid first, and then figure out what’s left over for you to take home.  This is not what you signed up for.

You branched out to call your own shots; to actually benefit from the hard work you are putting in.  So why are you more miserable working for yourself, than you were working for someone else (who may or may not have valued you)?

If only I had a good office manager; if only my front desk person didn’t quit; if only got paid on the patients that I saw.  When it comes down to it, not matter how idealistic you are about medicine, you still have a bottom line that needs to be met.  So why is it that the most important function after seeing patients is usually overlooked.  I am always surprised to see how little doctors know about their own billing.  One of the first questions I ask after learning about a providers practice is, “What is your collection rate?”

Most of the time, the response will be “It’s good”.  Or “I have a 30-60-90 report here”.  So, I simplify it.  How many claims last year were paid, divided by how many you submitted?  Rarely does a Doctor have this answer readily available.  They don’t even know where to find that information in their expensive PM software.

This is your income.  It is imperative you know where it is coming from, and where it is at all times.  The level of care you provide your patients matters; to an extent.  It will matter very little if you cannot keep your doors open to see your patients.  Or worse, if you are stuck in the middle of some conglomerate of medicine that are taking over the industry.  The entrepreneurial physician matters, and makes a difference.  But in order to continue mattering, you have to be profitable.  If providers were profitable, and were comfortable with their income, they would not be selling to these big hospital groups that are scooping up offices at an accelerated rate.  These big groups are run by business people.  They know how to be profitable.  The thing to understand is you can be profitable as well; while providing the kind of care you want to provide.

The entrepreneurial physician is an ideal to strive for.  Someone who provides great care, and someone who runs a great business.  Read any publications about being an entrepreneur and you will learn that building a great team is necessary; be it the right employees, or the right vendors.  And the entrepreneurial physician knows the value of data.  Data about their business, and other providers around them.  Having pertinent data grounds your decisions with facts.  And these decisions are the ones that will allow your practice to thrive.