CMS’s Latest CCM Code: 99491 – A Fast Way for Doctors to Lose a Lot of Money

(Authored by Jon-Michial Carter, CEO and Founder of ChartSpan, the country’s largest provider of managed Chronic Care Management services.) 

The Centers for Medicare and Medicaid Services (CMS) included a surprise in the 2019 Medicare Fee Schedule Final Rule.  They released a new Chronic Care Management (CCM) CPT code, 99491.  The new code reimburses providers who want to personally deliver CCM services to their patients at a national average reimbursement rate of $74.26.  It’s a ridiculous sum.

“99491 is foolish and a waste of time for physicians,” said Don Self, a leading medical reimbursement consultant.  Self bases his comments on the requirement CMS tied to 99491 mandating that any provider who bills 99491 must personally deliver the service to each patient, which means the service cannot be billed “incident to” and cannot be performed by a member of her or his clinical staff.  Further, 99491 requires a minimum of 30 minutes from each provider, unlike 99490 that can be billed “incident to” and requires only 20 minutes.

“Every doctor should be collecting a minimum of $400 per office hour worked,” said Self.  “Utilizing 99491, the most a provider could earn for providing CCM services is $149 per hour and that assumes 100% utilization. This code values a physician’s time at $150 per hour, costing them $250 per hour. It simply doesn’t add up,” said Self.

According to a recent report by The Physicians Foundation, “80% of physicians are at full capacity or are overextended.”  Does anyone believe adding another level of provider documentation and substantive time requirements will encourage providers to spend less time working and more time, face to face, with patients?

Two of the biggest challenges facing CCM are obtaining a patient’s voluntary enrollment and collecting the patient’s cost sharing obligation.

Prior to the first CCM billing encounter a verbal or written consent from the patient is required. The patient must agree to participate prior to billing any CCM encounter. Most providers who have attempted to bill CCM themselves will tell you that patient enrollment conversions were much lower than they expected and revenue never came close to expectations.

The average Medicare patient pays 20% coinsurance for E&M encounters like CCM. CCM is structured as a recurring monthly patient service.  If patients are not delighted with the monthly service being delivered, they often unenroll, due to the coinsurance and the perceived lack of value.  For CCM CPT code 99490, the national average reimbursement rate is $42, of which Medicare or Medicare Advantage typically reimburse $34, and the patient pays approximately $8.  For CCM CPT code 99491, the Medicare reimbursement is $59, while the patient has a monthly coinsurance of $15, resulting in nearly a 100% increase in the patient financial obligation.  The coinsurance associated with 99491 is a large pill to swallow for many Medicare patients on a fixed income.

On the heels of CMS’s recent release of claims data, showing that patients enrolled in a CCM program saw dramatic improvements in outcomes, there has been a ground swell of primary care physicians and specialists anxious to roll out a CCM program for their patients.  ChartSpan is admittedly not a neutral party when it comes to CCM.   ChartSpan assists practices, physicians and health systems across the United States with the provision of CCM services which may be billed “incident to.” We have built our business on providing CCM services to patients in partnership with our providers.  We understand the millions of dollars in data analysis/scrubbing tools, call center infrastructure, software technology, enrollment operations, quality assurance, clinical operations, telephony systems, operational oversight, and the support costs it takes to run a successful CCM operation.  The “opportunity cost” associated with CMS’s new 99491 code impedes a commensurate return on investment for providers.

If you have any questions, please feel free to reach out to me at JonMichial.Carter@ChartSpan.com.

Comments are closed.