Medicare Compliance & Reimbursement

Why an answering machine won’t meet the 24/7 requirement.

When it comes to billing the new chronic care management (CCM) services code 99490, there’s no shortage of questions from providers. Here are just a few of those frequently asked questions (FAQs): 

Question 1: 

What should we use as a date of service for CCM?

Answer 1: 

“CMS has not addressed this particular question,” answers Kent Moore, senior strategist for physician payment for the American Academy of Family Physicians (AAFP). CCM code 99490 encompasses a calendar months’ worth of work.

Try this: Consider entering the first day of the month in the “from” date for Box 24 on the CMS-1500 claim form, and the last day of the month as the “to” date for 99490 as a line item, Moore suggests. And because code 99490 encompasses the entire calendar month, “I would refrain from billing it until the last day of the month, in much the same way that CMS expects providers to wait until the end of the 30-day period to report transitional care management (TCM) codes.”

Question 2: 

CPT® code 99490 requires at least 20 minutes of time per calendar month by ‘clinical staff’ to bill the code. Who qualifies as ‘clinical staff?’

Answer 2: 

Physicians and certain non-physician practitioners qualify as clinical staff and may bill the new CCM service code, according to the Centers for Medicare & Medicaid Services (CMS). Eligible non-physician practitioners include certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants. Consult the CPT® definition of “clinical staff” for additional clarification if needed.

Keep in mind that only one practitioner may receive Medicare payment for the CCM service provided to a beneficiary for a given calendar month, CMS cautions. Also, you can count time spent by non-physician clinical staff only if you meet Medicare’s “incident-to” rules, such as supervision, applicable state law, licensure, and scope of practice.

Although other staff members may help to facilitate CCM services, you can count only time spent by clinical staff towards the 20-minute minimum time.

Question 3: 

There is a requirement that patients be able to reach providers 24/7. Does an answering machine meet the expectation?

Answer 3: 

No, this would not meet the requirement, according to CGS Administrators LLC. Access to care is a key requirement to submit claims for CCM. 

According to CMS, providers must “ensure 24-hour-a-day, seven-day-a-week access to care management services,” and patients must have “a means to make timely contact with healthcare practitioners in the practice who have access to the patient’s health record to address his or her chronic care needs.”