Greater scrutiny of CCM services could be on the way, perhaps even denials. So physicians should ensure they are coding the right way the first time.
• CPT code 99490 (CCM services, 20 minutes)
• CPT code 99487 (Complex CCM services, 60 minutes)
• CPT code 99489 (Each additional 30 minutes)
• HCPCS code G0506 (Comprehensive assessment of and care planning for patients requiring chronic care management services)
Payment information: CMS began paying for CCM in 2015, and many commercial payers followed suit shortly thereafter. The 2017 national average Medicare payment for CCM is $42.71. Medicare pays a national average of $93.67 for 60 minutes of complex CCM and $47.01 for each additional 30 minutes. The national average Medicare payment for a comprehensive assessment and care plan is $63.88.
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Even with Medicare’s adoption of chronic care management (CCM) codes, some physicians say they aren’t getting paid for performing these services. To complicate matters, CCM is also included in the Office of Inspector General’s (OIG) Work Plan for 2017, an annual report that summarizes the OIG’s new and ongoing reviews and activities to reduce fraud, waste, and abuse related to various Department of Health and Human Services programs and operations.
Experts say this means physicians will likely see greater scrutiny of these services and perhaps even additional denials.
One reason for denial might be that a patient’s diagnosis doesn’t warrant CCM services, says Kim Huey, MJ, CHC, CPC, an independent coding and reimbursement consultant. CCM is designed for patients with two or more chronic continuous or episodic health conditions (e.g., Alzheimer’s disease, arthritis, diabetes, or cancer) that are expected to last at least 12 months or for the rest of the patient’s life. To qualify for CCM, these conditions must put the patient at significant risk of death, acute exacerbation/decompensation or functional decline. Huey says she frequently sees internists try to bill CCM for uncomplicated diagnoses and subsequently be denied.
CCM denials also occur when a different provider (e.g., a specialist) has already billed these services for the same patient during the same calendar month, says Huey. She adds there is no real solution for this except to try and submit claims as soon as possible, because payers pay whichever claim they receive first.
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Prior to 2017, physicians might have seen CCM denials when they didn’t provide an initiating visit for established patients. As of January 1, 2017, an initiating visit is only required for new patients or patients who have not been seen in the practice within one year prior to the commencement of CCM.
The requirements for complex CCM are even more stringent. Not only must the patient meet CCM criteria, they must require moderate- or high-complexity medical decision-making and oblige the physician to spend at least 60 minutes performing CCM services per month. Another requirement is that physicians establish or substantially revise a comprehensive care plan. They can’t report complex CCM when the care plan is unchanged or requires minimal changes (e.g., changing a medication or adjusting a treatment modality).
According to CPT guidelines, adult patients receiving complex CCM are typically being treated with three or more prescription medications and who may need other types of therapeutic interventions, such as physical or occupational therapy. These patients also frequently require assistance with activities of daily living, care coordination between multiple specialists, ongoing social support, and treatment of psychiatric or other medical comorbidities that complicate their care.
Physicians should also be mindful of several important changes to CCM that took effect January 1, 2017. (Note: Prior to this date, payers could have denied CCM for non-compliance).
• Individuals providing CCM after hours are no longer required to have access to the electronic care plan if care plan information is available timely (i.e., promptly at an opportune, suitable, favorable, useful time).
• Physicians can provide patients with a copy of their care plan in any format-not necessarily an electronic format.
• Verbal consent to initiate CCM is allowed but must still be documented in the medical record, and the same information must be explained to the patient for transparency.
In addition, physicians can bill HCPCS code G0506 when they spend additional time at a face-to-face visit performing an extensive assessment and developing a comprehensive care plan for CCM. Bill it before CCM is initiated and only once per the patient for whom CCM is provided, says Huey.
For more information about these and other CCM changes for 2017, visit bit.ly/CCM-2017.