Your Guide to Maximizing your CPT 99490 Reimbursement – 2021 Edition

What is CCM? 

Before even thinking about billing for CPT 99490, providers should know the basics of what Chronic Care Management (CCM) is all about. The ongoing shift to value-based care has shown the need for more preventative programs that focus on addressing patients’ health conditions before they worsen. The intention of these programs is to improve patient outcomes, reduce healthcare spending, and reduce hospital readmission rates – all goals that are not only beneficial for the patient, but also for the healthcare system as a whole. Enter: Chronic Care Management, a program that focuses on managing Medicare patients who have multiple chronic conditions. In 2015, the Centers for Medicare and Medicaid Services (CMS) began reimbursing providers who offered CCM for their patients on a per month, per enrolled patient basis. Since then, the program has been proven to reduce hospitalizations by nearly 5%, reduce emergency department visits by 2.3%, and increase preventative care E&M encounters by 8%. 

What patients qualify for CCM?

Although preventive care is beneficial for everyone, the Chronic Care Management program focuses specifically on Medicare beneficiaries who have two or more documented chronic conditions in their health records. CMS defines chronic conditions as those that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline and last for the remainder of their life until the death of the patient. There is a long list of conditions that qualify, but some of the most common include diabetes, hypertension, depression, and hyperlipidemia. 

Patients can only be enrolled in Chronic Care Management under one provider, and they must have visited the provider within the past year to qualify for the program. All patients must provide their consent to be enrolled in the program, and are unable to unenroll at any time. At this time, most patients will require a small monthly copay to remain in the program. 

Who is allowed to provide CCM?

A wide variety of qualified health care professionals are able to provide Chronic Care Management services. This includes physicians as well as non-physician practitioners such as clinical nurse specialists, nurse practitioners, and physician assistants. While clinicians are able to perform general CCM functions, all medical decision-making is left up to the provider. Most frequently, primary care providers are the ones who offer CCM, however, several specialties are also qualified to offer CCM such as nephrology, urology, and cardiology.  

What are the requirements of CCM services?

In order to successfully bill for CCM services, providers must document a minimum of twenty minutes of clinical staff time per patient spent on care coordination. Care coordination activities include a wide variety of non-face-to-face care, including refilling prescriptions, coordinating transportation and appointments, follow-up, creation of care goals, and documentation of a care plan. A comprehensive care plan is one of the core requirements of CCM that must be documented in the electronic health record (EHR). The plan can then be shared with the patients’ other current healthcare providers as well as any caregivers so that the patients’ healthcare network stays connected. CCM services are billable once per calendar month that the patient is enrolled. 

What are the billing requirements of CCM? 

CPT code 99490 can be billed for the initial twenty minutes of non-face-to-face care provided and documented for the patient each calendar month. Reimbursement for this service can vary by state and practice type – for instance, Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) are typically reimbursed at a higher rate than a standard practice. Prior to billing for CCM monthly services (99490 or G0511) for the first time, you may elect to bill G0506, face-to-face CCM Consent, for patients as they come in to see their provider.  Those who provide continued care planning after the 20 minutes of billable time required for CPT 99490 within a month may be eligible to bill for Complex Chronic Care Management, which has additional requirements for clinical staff time and a higher level of medical decision-making.

If you have any questions about Chronic Care Management and the billing requirements, reach out to us and we will be happy to help.

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