Pediatric Coding Alert

Hint: eligibility, care plans, timing, and guidelines form the foundations.

On the surface, coding for chronic care management (CCM) and complex CCM seems fairly basic. After all, there are only three codes you need to know:

• 99490 - Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month ...
• 99487 - Complex chronic care management services ... 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
• +99489 - ... each additional 30 minutes of clinical staff time ...

The difficulty in coding these services, however, lies in the sheer number of guidelines coders have to follow. But these four easy-to-follow suggestions will help you record such services easily and accurately.

First, Know Who Is Eligible

According to CPT^®, the patient needs to suffer from "multiple (two or more) chronic conditions expected to last at least 12 months." In a pediatric setting, these could include such conditions as asthma, autism spectrum disorders, depression, diabetes, and neurological defects (For a more comprehensive list, go to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf).

Also, the CPT^® guidelines add, these conditions need to "place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline."

Second, Document a Care Plan

Once your provider has determined that a patient is in need of CCM, in order to report 99490/99487/+99489 you will need to document that your pediatrician has put a care plan in place. According to CPT^® guidelines, that plan should include "but is not limited to, the following elements":

• Problem list
• Expected outcome and prognosis
• Measurable treatment goals
• Symptom management
• Planned interventions
• Medication management
• Community/social services ordered
• Direction/coordination of agencies and specialists unconnected to the practice
• Identification of the individuals responsible for each intervention
• Requirements for periodic review, and, when applicable, revision of the care plan.

Third, Know When It's Time for CCM to Turn Complex

One of the biggest challenges facing coders documenting complex CCM is dealing with time-based guidelines. CCM itself is very straightforward. The 99490 code is "open-ended regarding time," explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, since the descriptor says "at least 20 minutes per calendar month." As the code is open-ended, Moore also notes there is no add-on code for 99490.

However, for complex CCM, patient care has to rise to a higher level, which is more time-consuming. In addition to the time spent creating a care plan, the care has to involve "moderate or high complexity medical decision making" (MDM) and the patient has to receive "three or more therapeutic interventions (eg, medications, nutritional support, respiratory therapy)."

So, the time threshold for 99487 rises to "60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month," while the add-on code, +99489, allows you to document an additional 30 minutes of clinical staff time.

That means for a complex CCM visit that lasts for 60 to 89 minutes, you would report 99487; for a visit lasting for 90 to 119 minutes, you would report 99487 and +99489 x 1; and for visits that last two hours or more, you would report 99487 and +99489 x 2, with additional units of 99489 for every 30 minutes beyond two hours.

Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, manager of clinical compliance with PeaceHealth in Vancouver, Washington, acknowledges that coding for time in these situations poses problems for coders. "Some practices do not even document this," Bucknam says, "so the codes cannot even be used." To remedy this, Bucknam suggests coders "create a process to track it or create a special build in your EMR to track and calculate minutes spent providing the service."

Fourth, Follow Even More CPT^® Guidelines

As if these rules weren't complex enough, CPT^® lists a litany of additional requirements that your practice will need to put into place to provide CCM for a patient. They include such things as:

• 24/7 access to physicians, qualified health profes­sionals, or clinical staff, with "timely access ... for follow-up after an emergency department visit or facility discharge";
• a member of the care team designated to coordinate the patient's care; and
• an electronic health record (EHR) system with a format standardized throughout the practice.

Additionally, CPT^® adds a large number of other services that cannot be reported with 99487 or 99490, which fall into two categories, according to Bucknam: "other types of services thatinclude CCM, like end stage renal disease/dialysis services, and services that are part of the CCM service itself, like telephone calls or educational material."

Bucknam goes on to note that "it is expected that these services will be provided as part of that month-long service. Or, as Moore puts it, "The prohibition on reporting is intended to avoid double-dipping by the practice."

But in the end, as difficult as it may be to document, such care makes a big difference in patient outcomes, with one study suggesting that the CCM model can improve those outcomes as much as "20 percent from baseline" (Source: http://www.jointcommissionjournal.com/article/S1553-7250(16)30092-7/fulltext).