Become a Care Management Coordination Supersleuth
Decipher the code descriptions and documentation requirements to determine when you can bill for non-face-to-face services.
When billing in the physician practice setting, frontline coders will be the first to tell you their providers do much more during their day than furnish outpatient evaluation and management (E/M) services (CPT® 99201–99205; 99212–99215). There is non-face-to-face work being done behind the scenes that, with a little investigation and research, you can capture and add to your practice’s revenue stream.
Rather than focus on one specific point in time, as with the outpatient E/M code set, care management codes often span periods of time and become cumulative as more services are rendered. Let’s look at some of the more commonly used non-face-to-face services, so by the time you finish this article, you can say, “Complex chronic care management? Anticoagulant management? Advanced care planning? Elementary, my dear doctor!” We’ll break each of these down and discuss what’s needed in documentation and how the 2021 E/M guidelines affect coding and documentation.
Complex and Non-complex Chronic Care Management
Chronic care management (CCM) is generally non-face-to-face services provided to Medicare patients who have multiple (two or more) chronic conditions (that is, conditions expected to last at least 12 months or until the death of the patient).
Non-complex CCM places most of the care plan firmly within the patient’s accountability. At least 20 minutes is spent, with the focus being to coordinate care across providers. This service is reported with CPT® code 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 … and is provided by the clinical staff under a provider’s direction.
Additional 20-minute increments of clinical staff time may be reported using HCPCS Level II code G2058 Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure). When the provider spends at least 30 minutes per calendar month implementing, establishing, revising, and/or monitoring the comprehensive care plan for a patient with two or more chronic conditions, report this service with 99491 Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month ….
These chronic conditions, which may include advanced cardiovascular conditions, such as congestive heart failure, and diabetes, place the patient at significant risk for acute exacerbation, acute decompensation, decline in function, and even death. The provider performs physical exams, manages medications, communicates with other treating healthcare professionals, and directs ongoing patient education, patient self-management, and outreach.
Note: For the purposes of this article, a clinical staff member is defined per CPT® as “a person who works under the supervision of a provider or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service, but does not individually report that professional service.” And a provider is a physician or other qualified healthcare professional such as a physician assistant or nurse practitioner. Services provided by a clinical staff member must be billed under a provider using the provider’s National Provider Identification (NPI) number.
Complex CCM involves, at a minimum, 60 minutes of services provided by clinical staff to substantially revise or establish a comprehensive care plan that requires moderate- to high-complexity medical decision making (MDM). A clinical staff member implements the care plan for a patient who typically has two or more chronic conditions. Clinical staff plays an important role in evaluating physical exams, developing and revising the plan of care, managing medication, communicating with other treating healthcare professionals, and most importantly, providing ongoing patient education and outreach and assessing patient self-management. The provider directs the clinical staff.
Use 99487 Complex chronic care management services … for 60 minutes of clinical staff time in which the provider directs them per calendar month with no face-to-face visit. When the clinical staff spends more than 60 minutes per month, use Complex Chronic Care Management Services code +99489 … each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure) in addition to the base code, 99487.
Critical takeaway: You may not report these codes together within the same calendar month. If you’re reporting 99490, with or without additional units of time represented by G2058, you may not also report 99491 or 99487 within the same month. Only one provider can assume the care management role for a patient and bill CCM services for that patient in a calendar month.
Anticoagulant management services underwent changes in 2018. Before 2018, 99363 and 99364 described 90 days’ worth of time during which a physician would review and interpret at least eight international normalized ratio (INR) measurements (initial therapy), adjust dosage, and order additional tests; or, in the case of each subsequent 90-day period, at least three INR measurements would be reviewed in addition to managing dosage and ordering additional tests.
Effective Jan. 1, 2018, CPT® deleted 99363 and 99364 and added 93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient’s/caregiver’s ability to perform testing and report results and 93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed to report training and management, respectively.
Note: You may report 93792 with an outpatient E/M service on the same date, but report 93793 only once per day, regardless of the number of INR tests reviewed.
Example 1: A patient presents to their cardiologist on Dec. 20, 2020, for follow-up on their atrial fibrillation (AFIB) and hypertension, and to initiate Warfarin therapy. The provider documents MDM of moderate complexity surrounding the hypertension and AFib. The provider then directs a nurse to train the patient on how to self-monitor their INR, while the provider reviews the dose of Warfarin the patient is to begin. The patient demonstrates competence and understanding, and the nurse notes this in the patient’s chart.
Coding: 99214-25, 93792
Example 2: The same patient as in Example 1 comes to the office on Jan. 4, 2021, for complaints of irregular heartbeat and headache. As they have run out of supplies to perform the test at home, their INR is also drawn. Two days later, the provider reviews the results of the previous two INRs, as well as the latest test results, and recommends a slight dosage change based on subtherapeutic levels, which the nurse communicates to the patient. The patient is instructed to follow up in three days for repeat INR.
Coding: Bill the appropriate E/M visit for the Jan. 4 visit, and bill 93793 with a Jan. 6 date of service. Even though the INR was drawn during the E/M visit, the definition of 93793 was not satisfied at that time, and anticoagulant management may not be billed on the same date as an E/M service.
Critical takeaway: While these codes carry an inherent face-to-face element, only one may be reported on the same date as an E/M service unless documentation shows that the E/M performed on the same date of service as 93792 is significant and separately identifiable.
Advance Care Planning
Advance care planning allows a patient to discuss their advanced legal directives face to face with their providers. Legal directives include healthcare proxies, durable power of attorney (POA) designations, living wills, and medical orders for life-sustaining treatment (MOLST).
Advance Care Planning code 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate describes the first 30 minutes of discussion that occurs on this topic, and +99498 … each additional 30 minutes (List separately in addition to code for primary procedure) describes additional 30-minute blocks that occur surrounding this discussion. Bear in mind that 99497 allows the “halfway-point” method: After 16 minutes have been spent, 99497 is billable. There is no limit on the number of times you can bill +99498 for a specific patient during a specific period. Documentation must include the changes that are being made regarding the patient’s end-of-life wishes.
Critical takeaway: As with all of the time-based E/M codes discussed so far, this time is independent and additional to what is already being spent on any applicable E/M. Documentation must clearly delineate how much time was spent on each service.
Example: A patient comes in with a new diagnosis of stage IV lung cancer and the provider counsels the patient for 40 minutes, face to face, regarding the treatment options and plan of care going forward. The patient then states they do not want extreme measures taken, and the provider spends an additional 20 minutes discussing living will, MOLST, and POA forms. The provider documents the following in the patient’s note: “I spent 45 minutes face to face with the patient, greater than 50% of which was spent reviewing treatment options and plan of care for stage IV lung cancer diagnosis. I then spent an additional 20 minutes discussing advanced care options including POA, living will, and MOLST forms. Patient is to see me in 3 weeks with these forms completed.”
Coding: 99215-25, 99497
Transitional Care Management
Transitional care management (TCM) describes a period of time, unlike most E/M services that are for a static point. Transitional Care Management Services codes 99495 Transitional care management services with the following required elements: communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit, within 14 calendar days of discharge and 99496 … medical decision making of high complexity during the service period; face-to-face visit, within 7 calendar days of discharge are for new or established patients whose medical and/or psychosocial problems require moderate- or high-complexity MDM while transitioning from an inpatient hospital setting to their community setting, be that their home, rest home, or assisted living. These codes cannot be billed for a patient transitioning from inpatient to a rehab facility or skilled nursing facility; the patient must cross from inpatient to community setting. The table below breaks it down further.
|Type of MDM||Face-to-face visit|
within 7 days
within 8–14 days
There are many requirements for billing these codes. As stated, place of service transition is the first requirement that must be met. The second requirement is that both face-to-face and non-face-to-face services are rendered. The first interaction with the patient upon discharge from their inpatient setting is typically rendered by a clinical staff member within two business days. Business days include any regularly scheduled weekend hours your practice has formally adopted. So, if the patient is discharged on a Thursday, and the provider regularly sees patients on Saturdays, then Saturday is the last business day to count as the two-day non-face-to-face contact.
The non-face-to-face contact may be conducted face-to-face in dire circumstances that require urgent maintenance by a provider face to face within 48 hours of a patient’s discharge. In this case, both the second and third requirements of this code set are met. The patient must be seen within 14 calendar days of discharge for TCM requirements to be fulfilled.
If a patient demands a faster response and is seen within seven days of discharge, assuming the two-day contact has been made and MDM is of high complexity, you may bill the encounter with 99496. As previously stated, TCM denotes a period of time rather than a static point. TCM services commence upon the date of discharge from the inpatient setting and continue for the next 29 days. The initial face-to-face visit within seven to 14 days is a requirement for billing this code and cannot be separately reported with an E/M code (99202–99205, 99212–99215). However, once the first face-to-face visit has been performed, you may be able to report additional medically necessary E/M services to monitor and maintain the patient’s chronic conditions.
A word of caution: TCM services are not meant to be billed for every single patient who has been admitted to the hospital and discharged; the goal is to reduce readmissions by providing access to community resources, educating family and caregivers about management, and performing close monitoring of the patient’s medical/psychosocial problems that pose a high enough risk to the patient that hospital care may be required. Additionally, only one provider involved in a patient’s care may report these codes in any given period. Usually, the patient’s primary care provider is the one who reports these codes, but the codes are not outside the realm of a specialist’s scope, so long as the specialist did not perform a procedure on the patient that carries a global surgical period.
Critical takeaways: These codes bundle almost everything we’ve discussed. Of the other care coordination activities discussed above, only advanced care planning may be reported at the same time/during the same period as TCM.
2021 E/M Guideline Changes Affect Care Management
Given the sweeping changes made to the 2021 outpatient E/M code set, it will be more important than ever that providers’ time language is concise and documented appropriately. As outpatient E/M code selection will be solely governed by either MDM or time, separation of services is crucial.
Additionally, time counted toward the outpatient E/M no longer needs to be specified as face-to-face; time spent on the same calendar day as the E/M service performing coordination of care, review of records, obtaining history, etc., may be counted toward the E/M service when billing based on time. While this may not pose an issue for the codes that describe periods of time, such as complex CCM and TCM, it’s a different story entirely for advanced care planning, which is completed same-day and time-based. To accurately support medical necessity for both services, the provider’s documentation of the E/M must either be MDM-based, or the time statement must be precise, to the point, and necessary. Should the provider choose to bill time-based, same-day coordination services on the same claim as an E/M, they will have to thoroughly describe their cognitive and temporal efforts in a statement that both compartmentalizes the blocks of time and supports medical necessity for both services on that date. Should the provider choose to instead bundle all time spent into the E/M, the content of the note must show some evidence that the higher E/M level is well supported based on the activities that took place on the date of service.
Every Bit Counts
Rounding out our practice to include some of these lesser-utilized services comes with rules, but they are not difficult to follow. By doing research and picking up on all the nuances offered by payers and CPT®, you can become an expert and capture these rare gems of reimbursement and knowledge for your practice’s use.
CPT® 2020 Professional Edition, American Medical Association: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf
2020 MPFS final rule: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F
2021 MPFS proposed rule: https://www.govinfo.gov/content/pkg/FR-2020-08-17/pdf/2020-17127.pdf