How to avoid common chronic care management denials

Published on: 
Medical Economics Journal, November 25, 2019 edition, Volume 96, Issue 22

Even though physicians have been able to bill CCM since 2015, they still run into problems in terms of getting paid.

Even though physicians have been able to bill CCM since 2015, they still run into problems in terms of getting paid, says Kim Garner Huey, CPC, owner of KGG Coding and Reimbursement Consulting in Birmingham, Ala. Here are some common reasons for denials and how to avoid them:

Reason for denial: Multiple providers bill CCM for the same patient during the same 30 days.How to avoid it: Communicate with specialists regarding who will bill for the CCM. “This code was really intended for primary care, but it’s not restricted to primary care,” says Huey.

Reason for denial: Physician bills CCM more than once every 30 days.How to avoid it: Set up an alert in the practice management system that prevents physicians from reporting CCM before 30 days have elapsed, says Huey.

Reason for denial: Insufficient documentation.How to avoid it: This problem often surfaces during post-payment audits, says Huey. Avoid recoupments by ensuring that documentation reflects the intent of the code-i.e. to manage all of the patient’s chronic conditions. “CMS intended a very personalized, hands-on type of medical management,” she adds. Documentation such as ‘Patient is taking medications as prescribed’ is not sufficient. Instead, she says to document the following:


  • List of all of the patient’s conditions with as much specificity as possible

  • Why these conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

  • Comprehensive care plan-What the physician is doing to manage the diagnoses. If a specialist is managing a condition, the primary care physician should note the specialist’s name, the date of the last appointment, and a brief summary of the visit.

For more information about CCM, including patient and practitioner eligibility as well as the service elements included in the code, visit the CMS web site.