The Top Ten Things You Should Know Before Billing CPT 99490

01-99490-billing-guidelines

Article Updated for 2021

Your Guide to Maximizing your CPT 99490 Reimbursement – 2021 Edition

CPT 99490 covers chronic care management services for qualified patients. Understanding CCM 99490 billing requirements can help you ensure your clinic receives reimbursement for your CCM services. Continue reading to learn more about CCM 99490.

What Is CCM 99490 Billing?

More than 40% of the United States population is affected by chronic conditions. The Centers for Medicare and Medicaid Services (CMS) defines chronic conditions as those in which the patient is at significant risk of death, acute exacerbation/decompensation or functional decline and are expected to last until the patient’s death. It only makes sense that a health care program designed to promote health maintenance and prevention for the chronically ill is needed. 

That is why in 2015, CMS began reimbursing providers for a program called non-complex Chronic Care Management (CCM), billed as the new code CPT 99490. CPT 99490 covers at least 20 minutes of non-face-to-face chronic care management services provided by clinical staff.

The program is intended to service Medicare patients with two or more chronic conditions and is a non-face-to-face service. This focus on care coordination is intended to prevent chronic conditions from worsening, preventing unnecessary hospital admissions and ED visits and saving patients and Medicare money every year.

For a provider to bill for the 99490 CPT code, the first step is to obtain documented patient consent to participate in the program, ensuring the patient understands and agrees to pay associated copays and deductibles related to the service. 

CCM Service Requirements

Once the patient is enrolled, CCM services require 20 minutes of clinical staff time each month devoted to the patient, which must be documented in a comprehensive care plan. That care plan must be made available monthly to all care providers in that patient’s care continuum. This seems simple enough. However, several common questions arise when billing for a CCM program.

1. What Counts as Staff Time and Which Care Providers Can Participate in Chronic Care Management?

Since CCM billing requires 20 minutes of staff time, it’s important to understand what staff time entails. CPT defines staff time as services provided by a staff member who meets the following requirements:

  • Works under a qualified health care professional’s supervision.
  • Meets facility regulations and policies qualifying them to legally assist in or perform specified professional services.
  • Does not individually report professional services.

A clinical staff member is legally allowed to perform medical services under a physician, physician’s assistant or nurse practitioner’s supervision. You can also bill CCM 99490 if a physician, physician’s assistant or nurse practitioner directly provides non-face-to-face services for a patient. Primary care and a variety of specialties qualify to provide these CCM services. Likewise, physicians and the following non-physician practitioners can bill for CCM services:

  • Clinical Nurse Specialists
  • Nurse Practitioners
  • Physician Assistants
  • Certified Nurse Midwives

2. What Are the Requirements of a CCM Service?

CCM services require documentation of 20 minutes of non-face-to-face care per enrolled CCM patient per calendar month to bill. Care coordination can encompass a variety of activities that benefit patients with chronic conditions, such as refilling prescriptions, assessing fall risk, arranging follow-up appointments, requesting medical records, arranging transportation, and updating medical records.

All care coordination activities must be documented in a comprehensive care plan. Once the 20 minutes is complete, the provider can bill CPT code 99490 to Medicare for reimbursement. CCM services must satisfy the following elements:

  • 24/7 patient access to care management services.
  • Multiple communication methods for patients and caregivers to reach providers such as the patient portal, email and phone.
  • Care continuity.
  • Chronic condition care management such as medication management and patient need assessment.
  • Patient-centered care plans including an electronic or written patient copy.
  • Coordination with community-based and home-based clinical service providers.
  • Care transitions management such as follow-up care and referrals.
  • Care plan information sharing via electronic capture, such as in the Electronic Health Record, so CCM service providers have 24/7 access to patient records.

3. Can CCM Be Billed on the Same Day as a Provider Office Visit or Hospital Visit?

You can bill CCM on the same day as a provider office visit or hospital visit, but you will need to use a 25 modifier. Another option is to move the CCM Date of Service (DOS) to the following day for office visits and following discharge for hospital stays. The alternate dates must lie within the billing month. You can bill CCM and emergency or medical visits on the same day as long as you count the service time only once.

Do not count any time toward CPT 99490 if you would otherwise consider it part of the emergency or medical service the patient receives. If you bill the CCM code and the emergency or medical visit on the same day, you must report modifier -25 on the CCM claim.

It is also important to remember you can bill CCM and annual wellness visits in the same month. CMS requires providers to perform an annual wellness visit before billing CCM, and providers may initiate CCM services during this visit or in the same month as this visit.

4. What Date of Service Should Be Used in the Claim?

The day 20 minutes of billable time is reached is the best DOS to use in your claim. However, you can use alternate dates as long as 20 minutes of billable time is completed on or before the last date of the month in that billing month.

5. Can Providers Bill More Than One CCM Claim for a Patient Per Calendar Month?

Providers can only bill one CCM claim per month. This is because CCM claims must be 30 days apart.

6. Are There Specific Codes or Services That Can and Cannot Be Billed in the Same Month as Chronic Care Management?

Qualified healthcare professionals cannot bill for CCM services during the same service period that another facility or practitioner is providing care management. In addition, the services listed below and their corresponding codes cannot be billed within the same month as CCM:

  • Home Health Care Plan Oversight CPT code G0181
  • Hospice Care Supervision CPT code G0182
  • Specific End Stage Renal Disease CPT codes 90951 – 90970
  • You cannot bill CCM while a patient is in a Skilled Nursing Facility.

You can, however, bill CCM services while patients are in a nursing home or assisted living as long as the facility is not billing for CCM or Home Health Supervision, code G0181. Lastly, new in 2020, you can bill Transitional Care Management (TCM) CPT 99495/CPT 99496 and CCM in the same month.

7. Is It Required to Speak to the Patient Monthly to Bill for Chronic Care Management?

No. While every attempt should be made to reach each enrolled patient every month, some patients will likely choose not to engage in any given month. This does not mean you cannot bill during a month when the patient cannot be reached. As long as 20 minutes of meaningful clinical staff time, such as chart work and care coordination activities, are completed, you can, and should, bill for the service.

8. Who Collects the Coinsurance?

The healthcare provider is responsible for collecting the 20% coinsurance for traditional Medicare plans. The cost will vary for Medicare Advantage plans. If CCM is outsourced to a partner, the billing provider is still responsible for collection.

9. How Do You Actually Complete a Claim?

Follow these steps to complete a claim for Chronic Care Management:

  • Use 99490 for 20 minutes of service, regardless of the time over 20 minutes.
  • The place of service should be listed as the provider’s office or location code 11.
  • Bill under Medicare Part B.
  • When billing manually, use the “Date of Service” listed from the clinical record.
  • If you receive a denial because the patient was in the hospital or provider’s office on the same day they were billed for CCM, you can move the CCM date until the day after without penalty.
  • If a patient has a Medicare Advantage plan as primary and Medicare as secondary and gets a denial from the Medicare Advantage plan, you can then submit billing to Medicare for reimbursement.

10. Where Can You Find More Information on Chronic Care Management Billing Requirements?

A Fact Sheet on CCM billing requirements is available on the CMS website. You can use this resource to learn more about CCM services and billing requirements.

CCM Reimbursement Tips

Following these CCM reimbursement tips can help your clinic receive reimbursement for your services. Use the following steps to help you receive reimbursement from the government:

1. Patient Consent

Patients must also give verbal or written consent to participate in a CCM program. Patients cannot participate in or be billed for a CCM program without meeting the criteria and providing their consent. Asking for patient consent ensures each patient understands the financial implications and proposed medical services before entering the program. Physicians create their own agreements, but each agreement should accomplish the following:

  • Explain all available services: The patient should be aware of what services are included in the CCM program.
  • List cost-sharing expenses: Patients must also be aware of any expenses they will be expected to pay such as co-payments.
  • Explain how to discontinue services: Patients may cancel CCM services by revoking their agreement, and their services will discontinue at the end of the month they cancel them.
  • Describe CCM billing limitations: The agreement should explain to the patient that CCM only reimburses one practitioner each calendar month.
  • Obtain the patient’s authorization: The agreement must include documentation of the patient’s authorization to receive services and allow providers to electronically communicate medical information.

Providers must clearly document the above information in the patient’s medical record and within their patient agreement. Providers must also document any CCM service changes, consents and revocations.

2. Timeframe and Services 

There are various CCM services, and each differs in the extent of care planning, the amount of clinical time provided and the level of involvement of the billing specialist, with their codes for each changing based on these variables. For example, standard non-complex CCM appointments provided by a physician are coded as CPT 99490, while every additional 20 minutes of the service supplied is coded as CPT 99439, so long as it doesn’t reach over 60 minutes. 

Federally Qualified Health Centers (FQHCs) must remember that they’re responsible for crosswalking the CPT codes to the billable G codes. 

3. Initiating Visit

New patients or patients who haven’t been seen within the last year must participate in a comprehensive initiating visit. Patients who have been seen within the year are fair game for the program. There are various types of initiation visits, such as:

It’s important to note that the initiating visit is not part of the comprehensive CCM services and must be billed separately. It’s not essential to discuss CCM services during the visit, but it must occur 12 months before the start of a CCM program.

4. Documentation

Providers need to document all of their CCM services for 20 minutes or more to secure reimbursement. Providers can utilize EHR technology to record patient health information, which includes:

  • Medications and allergies
  • Demographics
  • Care coordination
  • On-going clinical care

This information is essential for the billing and care process to ensure patients receive the appropriate treatment and that clinics are reimbursed for their services. CCM services include a broad range of things and must be outlined in a care plan created by physicians and shared with providers and patients. Care plans can also be updated depending on the patient’s treatment needs.

5. Authorized Provider and Staff

CCM services can be performed by a wide variety of professionals and is not limited to doctors and nurses. Under the direction of a medical provider, 20 minutes or more of CCM staff resources may be provided under general supervision. Non-primary care providers must consider licensure, state law and practice definitions. 

6. Coding and Billing

Using the proper codes ensures that your clinic uses billing for the proper services and can receive adequate reimbursement. For example, new codes were added in 2021, G2064 and G2065, which help clinics bill for clinical staff services that help patients manage chronic conditions requiring substantial care. FQHCs can bill using these codes under G5011 but cannot be billed concurrently with the same billing practitioner for CCM services.

FQHCs and rural health clinics (RHCs) can submit Medicare claims for CMS PPS “G” code visits that are billable and single claim care management services. Using the correct codes helps FQHCs and RHCs receive adequate reimbursement from Medicare for their services.

Free up Your Staff With a Comprehensive CCM Program

ChartSpan offers Chronic Care Management solutions via innovative software and a highly trained team. Our CCM solutions make up one of the nation’s most successful CCM programs. ChartSpan gives your patients 24/7 care management access with an experienced team that serves as an extension of your care team.

With ChartSpan’s CCM program, your staff can focus on providing in-person patient care while we handle the rest. Your staff can devote more time to patients while we address tasks such as the following:

  • Medication assistance refills.
  • Continuous comprehensive care planning for each patient.
  • Support that helps providers and patients reach their established health care goals.
  • Assistance accessing tests, X-rays and labs.
  • Transportation assistance and support with mobility needs.
  • Support for family members and caregivers caring for individuals.
  • Assistance with scheduling specialist or doctor appointments.
  • Support for individuals facing social health determinants.

Choose ChartSpan as Your CCM Solution

Understanding which codes to use can help and ensure that clinics are reimbursed for their CCM services. ChartSpan assists clinics with their Chronic Care Management Program to help them manage their services, use the appropriate billing codes and retrieve reimbursement from the government. Our CCM services also help our clients focus on their in-person clinical care, meaning we handle the rest, including small administrative tasks.

Our program can help practices and hospitals increase their monthly revenue, retain Medicare patients, identify care gaps and improve patient outcomes. Book a demo with us today to learn more about how our CCM program can be a solution for you.

Published: August 12, 2020

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