Medicare Compliance & Reimbursement

Don’t try to bill certain services during the same month as CCM.

If you’re not billing chronic care management (CCM) services correctly, you’re leaving deserved Medicare reimbursement on the table. And falling into a myriad of hidden traps when coding CCM services is pretty easy to do.

As of Jan. 1, Medicare will pay you separately under the physician fee schedule for CPT® code 99490 for non-face-to-face care coordination services with multiple chronic conditions. The Centers for Medicare & Medicaid Services (CMS) defines such CCM services as at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the patient’s death;

• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and

• Comprehensive care plan established, implemented, revised, or monitored.

The requirements for billing and obtaining reimbursement for CCM services with code 99490 are extensive and, in some cases, confusing. Here are the most common mistakes you can make when billing for CCM:

1. Don’t Skimp on Documentation

A big mistake that you can make when providing CCM services is not documenting the necessary 20 minutes or more of clinical staff time, says Kent Moore, senior strategist for physician payment for the American Academy of Family Physicians (AAFP). Also, don’t count non-clinical staff time as part of the 20 minutes.

CMS has not specified how practices should document the time spent on CCM services, but an auditor would likely look for some record of who (clinical staff) provided CCM services, on which dates, and for how long. Although you might be able to use your electronic health record (EHR) system to document these details, some EHRs are not set up to capture documentation in this way. 

Because this is a timed code, you must document the time spent providing non-face-to-face CCM services as either total time or start/stop times, according to CGS Administrators LLC.

Tool: Try using a service log spreadsheet to document CCM services, available from the AAFP’s Family Practice Management Toolbox at http://bit.ly/1G3LEQY. 

2. Beware of Billing These Services With CCM

“Be aware of what you can and can’t bill with CCM services,” Moore warns. You cannot bill for these four services within the same calendar month as CCM:

• Transitional care management (CPT® 99495 and 99496);

• Home healthcare supervision (HCPCS G0181);

• Hospice care supervision (HCPCS G0182); and

• Certain end-stage renal disease (ESRD) services (CPT® 90951 – 90970).

3. Avoid Losing Precious E/M Reimbursement

You can, however, bill separately for E/M and CCM services. A mistake that many providers could make is not billing for E/M services for the visits with the patient during the same month as CCM services, Moore tells Medicare Compliance & Reimbursement Alert.

Aside from the four codes listed above, “I am not aware of anything that would prohibit you from reporting 99490 in the same calendar month during which you saw the patient and reported an appropriate [E/M] code for that encounter,” Moore notes.

Remember: You can bill only one E/M service per day unless you can meet the conditions for using modifier 25, according to a recent FAQ publication. You cannot count face-to-face time that you would otherwise consider part of the E/M service towards CPT® 99490 — you must count towards 99490 only the time that clinical staff spends providing non-face-to-face services within the scope of the CCM service.

What to do: If you need to bill both an E/M and the CCM code on the same day, you must report modifier 25 on the CCM claim, CMS instructs.

4. Skip CCM Billing for Inpatients

You cannot bill CCM services for patients who are in a nursing facility or a hospital, Moore states. Medicare won’t reimburse CCM services while a beneficiary is an inpatient.

Reasoning: In the 2014 Medicare physician fee schedule final rule, CMS explained that “the resources required to provide care management services to patients residing in facility settings significantly overlaps with care management activities by facility staff that is included in the associated facility payment.”

5. Watch Out for Place-of-Service Blunders

Another confusing factor when billing for CCM is the place of service (POS), because these are not face-to-face services. Don’t be tempted to code the POS as “home,” even if the patient is at home when you’re providing CCM services, Moore cautions. Instead, the POS should be where the practitioner is when providing the services — typically in your office.

Rule of thumb: You should code the POS so that it reflects where staff rendered the majority of services. For CCM services, POS 11 (Office) or 22 (Outpatient hospital) would apply. “Payment for CCM furnished and billed by a practitioner in a facility setting will trigger physician fee schedule payment at the facility rate,” CMS notes.

6. Be Careful When Billing MA Plans

Despite initial confusion over whether Medicare Advantage (MA) plans would cover CCM services at all, CMS has confirmed that CCM is a covered Medicare Part B service included in the basic benefit offered by every MA plan, according to AAFP. But this doesn’t mean that billing for CCM services will be the same for MA plans as traditional Medicare.

“Another mistake is assuming that MA plans will handle CCM claims the same way as traditional Medicare,” Moore points out. “CMS gave MA plans ‘wide latitude’ on how to handle these claims.”

In a recent memo, Kathryn Coleman, director of the Medicare Drug & Health Plan Contract Administration Group, stated that MA regulations “expressly preclude CMS from interfering in payment rates agreed to by an MA plan and its contracted providers,” and whether such a plan pays physicians for furnishing care coordination via the CCM CPT® code 99490 or some other mechanism “can vary depending on the contract agreement in place.”

7. Don’t Routinely Waive Coinsurance & Deductibles

Finally, make sure you aren’t routinely waiving coinsurance or deductibles for CCM services on a regular basis, Moore says.

Don’t forget: Additionally, remember to gain the patient’s written consent prior to providing CCM services, as well as provide a face-to-face visit to initiate the CCM service (any face-to-face encounter will work), Moore advises.

Resources: A CMS fact sheet on CCM services is available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. To view the CMS FAQ document, go to www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1516.pdf.