EM Coding Alert

A chronic care management (CCM) program can be a win-win for everyone concerned. It benefits the patient as it results in “improved care,” benefits the practice as “the care team gets paid for services delivered,” and benefits us all as it “reduces hospitalizations and emergency room visits,” according to Samuel L. “Le” Church, MD, MPH, CPC, CRC, FAAFP, of Synergy Health, Inc., Hiawassee, Georgia.

His HealthCon 2020 presentation, “Jump Start Your Chronic Care Management Program,” provided some valuable insights and suggestions for starting a new program or enabling an existing one to succeed. Here are the highlights.

Know What Goes Into CCM

For a CCM program to work, you first need to know that CCM services “require that the patient have two or more chronic continuous or episodic health conditions expected to last at least 12 months, or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,” according to CPT^®. However, “there are no clear rules on ICD-10 codes for CCM,” Church notes.

You must also document “a care plan and at least 20 minutes of non-face-to-face team care in one calendar month,” Church adds. For that, you use 99490 (Chronic care management services, at least 20 minutes of clinical staff time … per calendar month….) with G2058 (Chronic care management services, each additional 20 minutes of clinical staff time … per calendar month …) for each additional 20 minutes over the initial 20. For services lasting at least 30 minutes per calendar month and provided personally by “a physician or other qualified health care professional,” or QHP, you would use 99491 (Chronic care management services, provided personally by a physician or other qualified health care professional …).

Don’t forget: “CCM services also require patient consent. CMS [Centers for Medicare & Medicaid Services] allows verbal consents, but it is still a best practice to have such consents in writing,” Church cautions.

You need consent because “there is patient cost-sharing involved. CMS wants to ensure Medicare beneficiaries understand that in advance since much, if not all, of the service is non-face-to-face and won’t be as apparent as, say, care during an office visit,” points out Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Know How to Handle Patients With Single or Complex Conditions

When physicians or QHPs provide similar services to patients with a single high-risk disease, you can use G2064 (Comprehensive care management services for a single high-risk disease … at least 30 minutes … per calendar month…) for principal care management (PCM), while you would report PCM provided by clinical staff under the direction of a physician or QHP with G2065 (Comprehensive care management for a single high-risk disease services, e.g. principal care management, at least 30 minutes … per calendar month…).

“Like G2058, these codes are new for 2020. CMS established them within the context of the Medicare program, but nothing prevents other payers from covering and paying for them,” notes Moore.

Complex CCM is also “similar to CCM, so it must be directed by physicians or QHPs, but it requires them to use moderate or high-complexity medical decision making. In addition, it requires 60 minutes or more of clinical staff time per calendar month,” Church explains.

Services meeting these criteria can be coded with 99487 (Complex chronic care management …) if they last between 60 to 89 minutes in a given calendar month. Time over and above 89 minutes can be recorded in increments of 30 minutes using the add-on code +99489 (… each additional 30 minutes … per calendar month …).

Coding caution: Even though time is measured per month, “monthly billing is not required. Additionally, administrative time, including charting CCM, counts toward CCM time, but time counted does not carry forward to following month, so tracking time is a challenge,” Church admits.

Know What Activities Count, or Don’t Count, in a CCM Program

“Most anything in support of the overall care plan, including medication management, family and patient follow-up phone calls, and even mining consult notes, can be counted toward time spent on CCM,” says Church.

However, “you cannot double-dip for some separately reportable services, such as the following, when you’re otherwise counting the time of those services toward the CCM being billed,” says Moore:

• Care plan oversight services using G0181 (Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency … involving regular physician development and/or revision of care plans … 30 minutes or more) or G0182 (Physician supervision of a patient under a Medicare-approved hospice … involving regular physician development and/or revision of care plans … 30 minutes or more).
• Patient-initiated digital communication using 99421-99423 (Online digital evaluation and management service …).
• Self-measured blood pressure monitoring using 99474 (Self-measured blood pressure …).

“Remember, you cannot bill for work overlapping with other evaluation and management [E/M] visits, work by nonclinical staff, or anything outside of the care plan,” Church cautions.

The Final Word

“Medicare estimates that approximately two-thirds of their patients are eligible for CCM,” Church notes, which means if your practice has a high percentage of Medicare patients, a CCM program is not just a good idea, it’s also good business.

“Just start with a small number of patients and work up,” Church advises.