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Getting paid for chronic care


Beginning January 1, 2015, medical practices can, for the first time, bill Medicare for the non face-to-face time spent managing care for patients with multiple chronic diseases. But doing so may prove challenging for many practices, at least at first.

The 2015 Medicare Physician Fee Schedule includes a Current Procedural Terminology (CPT) Code-99490-that pays for clinical staff time, directed by a physician or other qualified healthcare professional, in “developing and implementing a care plan for a patient with at least two chronic conditions that are expected to last at least 12 months or until the death of the patient; or that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,” according to the Center for Medicare and Medicaid Services.

Payment is $42.60 for 20 minutes of staff time. The code can be billed once per patient per calendar month.

“This is in response to concerns from primary care physicians that they spend a lot of time trying to coordinate care to manage all the different healthcare contacts the patient has,” says Cindy Hughes, CPC, CSBC, principal of Cindy Hughes Consulting and a former coding and compliance consultant for the American Academy of Family Physicians. “The code was developed especially to address staff time spent on those activities, as well as the physician’s time coordinating that work and supervising the staff.”

“Very rarely do you have people with just one chronic illness that’s easily handled,” adds David Ellington, MD, FAAFP, a member of the American Medical Association panel that develops the CPT codes. “You find chronic medical illness associated with psychiatric illness and developmental problems, and these require a great deal of time to coordinate the care that falls outside the time constraints of the normal evaluation and management codes. Medicare recognized this a couple of years ago and the CPT editorial panel has been trying to refine the codes so as to reflect the spectrum of clinical staff time required to take care of these folks.”

Continuation of a trend

Approval of the code is significant for two other reasons as well, explains Shari Erickson, MPH, vice president of government and regulatory affairs for the American College of Physicians.

Shari Erickson, MPHFirst, because it continues the trend of Medicare paying for non face-to-face care it began last year with approval of the transitional care management codes.

Read: Transitional care management codes: What physicians should know

Second, because it acknowledges and starts to address the large and growing share of the nation’s healthcare spending devoted to people with multiple chronic conditions. A 2013 study by U.S. Department of Health and Human Services found that about 25% of the nation’s adult population has multiple chronic conditions, the care of which accounts for 66% of the nation’s overall healthcare spending. The two-thirds of Medicare beneficiaries with two or more chronic conditions accounted for a whopping 93% of that program’s spending, according to another study from 2013 by the Centers for Disease Control and Prevention.

Using the CCM code, Erickson says, will give researchers data with which to begin analyzing the care provided to patients with multiple chronic diseases and find out what works in reducing high-cost outcomes such as hospital admissions and emergency department visits.

Next: The limitations on CCM code use


While the new code could result in an income boost for some primary care practices, especially those with large Medicare populations, it also comes with scope-of-service and billing requirements that could limit its use. (See accompanying sidebars, “Chronic care management: Scope-of-service requirements” and “Chronic care management: billing requirements” for additional details.) Three in particular will present challenges to many practices.

First is the requirement that all CCM-related services be performed using 2011- or 2014-certified electronic health record (EHR) systems, and that patient records be accessible to other members of the patient’s care team. (See “Chronic care management, scope-of-service requirements.”) That means practices not using EHRs, or using older systems are not eligible to bill the code.

In addition, the lack of interoperability among EHR systems could make it difficult to share patient information among care providers in different locations. “There will definitely need to be some workarounds, given that most EHRs aren’t capable of doing all the moving parts required in the code,” says Erickson. “That may be easier for larger practices but it will be a real challenge for smaller ones.”


A second challenge will be tracking the time spent on the activities covered under the code, says Nancy Enos, FACMPE, principal

Nancy Enos, FACMPEof Enos Medical Coding in Warwick, Rhode Island. 

“It’s going to involve pulling some of the clinical staff into a process that’s not usually tracked very well, because it doesn’t involve face-to-face care,” says Enos. “It means documenting who they talked to, what they did, why they did it through the course of the month.”

Enos and other coding experts recommend that practices develop a “flow sheet” for use in tracking and documenting the time spent on each patient’s CCM-related services, then tallying the time at the end of each month to see if it reaches the 20-minute threshold. But doing so will probably require a paper-based process, at least at first, because EHR systems aren’t set up to capture time in that way, notes Terry Mills, MD, FAAFP, director of patient care systems for Via Christi Health in Newton, Kansas.

“No EHR system that I’m aware of now logs time in that way and will automatically calculate it and give you a report,” he says. “If you’re doing it for a small number of patients you can keep paper logs and track all the minutes. But then, frankly, the return probably isn’t worth the hassle.” And while customizing an EHR to capture the time may be technically possible, “it may be too expensive for practices to engage their vendors to do this,” says Erickson.

Next: Who qualifies for coverage?


A related challenge may be just deciding who qualifies for coverage under the code, Mills adds. “Any 70-year-old with hypertension or diabetes is at risk of decompensation or death within the next year,” Mills says. “So is that the type of patient they mean, or is it someone who’s sicker than that? Our compliance department is unwilling to let us build a system to bill for that population until that population is better defined.”

But the biggest obstacle many practices could face may be in obtaining patients’ consent to provide chronic care services, and to pay the required $8 monthly copay. “It’s going to be a very tough thing to get across,” says George G. Ellis, Jr., an internist in Youngstown, Ohio, and Medical Economics’ chief medical adviser.

Ellis says he will explain it to patients as “an attempt to control your disease process, and enable you to connect with your care team 24/7, 365 days a year to reduce or eliminate emergency department visits and hospitalizations.” Related to that, Ellis notes, is the question of what happens if the patient doesn’t provide his or her consent, especially since the physician almost certainly is already performing many of the services covered in the code.

Doctors won’t stop monitoring the patient’s health or responding to his or her needs, but “it’s long overdue that we get paid for the services we provide,” Ellis says.

(A request to CMS for comment had not been answered at press time.)

The patient consent requirement was included so as to encourage “patient engagement and shared decision-making around care, because there’s an evidence base around its benefits in terms of patient outcomes and savings,” says the ACP’s Erickson. “But we are concerned that patient consent puts physicians in the position of having to sell this service to their patients in a way that may be uncomfortable because perhaps they have been providing these services already but not in a way that’s transparent to the patient.

“We’re hoping that as more patients and clinicians become familiar with these services it’s not such an issue,” she adds. “But it will definitely be a learning curve on both sides.”


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