CMS okays new payments for chronic care management

While healthcare providers often provide non-face-to-face chronic care management (CCM), until recently Medicare had not paid for them separately. Instead, providers received compensation for these services as part of the face-to-face E&M visit payment. The Centers for Medicare and Medicaid Services (CMS) recently instituted billing code CPT 99490, in the 2015 Medicare Physician Fee Schedule (MPFS), finally reimbursing providers separately for these non-face-to-face services.

The code reimburses providers about $41 per patient per month, defined as: “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 required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.”

Navigating the billing requirements for this code is complex. The following summarizes some key issues to know:

Informed Consent: Written patient consent must be obtained before providing CCM to ensure patients understand their 20% coinsurance payment and deductible obligations.

Certified EHR: An electronic health record (EHR) that meets the certification requirements for the 2011 or 2014 edition of the certification criteria for the EHR Incentive Programs is mandatory for a number of the CCM billing requirements.

CCM Services: CMS defines CCM to include providing care management services on a 24/7 basis, ensuring continuity of care with a designated practitioner or member of the care team, case management for chronic conditions, and creating a care plan.

Clinical Staff: CMS permits CCM to be provided by “clinical staff” but does not specifically define the term. Without further guidance from CMS, providers should consider having licensed professionals, such as physician assistants and nurses, provide the CCM.

Counting the 20 Minutes: CMS has laid out a number of requirements for counting the required 20 minutes of CCM. For example, providers may not round up to the 20 minutes. Only CCM services provided by clinical staff under general supervision of a physician or non-physician practitioner may be counted. Each discrete service may only be billed once and the time of only one clinical staff member may be counted for a particular segment of time. Such requirements will require providers to diligently document their CCM.

Limitations on Billing: A practice billing for CCM may not also bill for certain other services, such as transitional care management, home healthcare and hospice care supervision, and certain end-stage renal disease services.

Face-to-Face Visits: Ironically, given CMS’ growing recognition of the value of non-face-to-face CCM services, perhaps the biggest open question is whether an initial face-to-face visit is required for initiating and billing for CCM. Under the 2014 MPFS final rule, CMS clearly “changed [this] requirement to a recommendation.” However, in a February 2015 teleconference, CMS informally advised that CCM services must be initiated during a face-to-face visit. Therefore, without further formal guidance from CMS it remains unresolved whether providers must initiate CCM services through a face-to-face visit.

Scott Edelstein is a partner with Jones Day in Washington D.C. and David E. Koppans is an associate with Jones Day in Columbus, Ohio.