Jumpstart Your Chronic Care Management Program

Jumpstart Your Chronic Care Management Program

Improve patient care and increase your practice’s bottom line.

In 2015, the Centers for Medicare & Medicaid Services (CMS) began paying separately under the Medicare Physician Fee Schedule for chronic care management (CCM) services. CCM is a covered benefit for Medicare patients who have two or more chronic conditions — about four in 10 adults in the United States.

At AAPC’s HEALTHCON 2020, family physician and advisor for the CPT® Editorial Panel Samuel “Le” Church, MD, MPH, CPC, CRC, CPC-I, FAAFP, shared his knowledge about CCM. Church has been an ambassador for CCM since its inception, sharing his knowledge with providers and teams across the country. In his presentation “Jumpstart Your Chronic Care Management Program,” Church makes his case for starting a CCM program.

What Is CCM?

CMS defines CCM as “care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.” It’s similar to CMS’ principal care management services, which provide care to patients diagnosed with a single chronic condition expected to last between three months and one year.

The goals of a CCM program are to:

  • Reduce hospitalizations;
  • Reduce emergency visits;
  • Improve overall care; and
  • Pay care teams for delivered services.

CMS’ decision to reimburse for CCM services was in line with its goal for replacing procedural-based payment with payment tied to value-based care. Regarding projected federal healthcare spending, Church says, “It is crystal clear that we’re not getting bang for our bucks that are invested in care management in the way we’re delivering things now.” Church goes on to say, “This is something that makes care better and pays for itself, as well.” Medicare estimates that two-thirds of Medicare patients are eligible for CCM, so the program not only steps up patient care and health outcomes but can also be an added source of revenue for practices.

Why Are Coders Important for CCM?

Church explains that a CCM program is truly a team effort. He notes that if the practice management team is not on board, a CCM program cannot be implemented and sustained. The role of coders in starting and delivering a care management program can’t be overemphasized. “We need QHP [qualified healthcare professional] and staff champions,” says Church. “We need practice managers and coders who say, ‘this could really work!’”

Starting a CCM program needs to be viable for your practice, however. While better system costs and better patient outcomes are well documented, is offering patients CCM better for your practice? Before deciding to adopt a CCM program, consider what the goals of care are for the entire team. “Having the right staff on board as liaisons and team leaders makes all the difference,” says Church. He notes that previous care management experience is great, though not required for those leading the charge. Office experience is a must, however, and staff should be trained across the board, starting with the check-in desk.

Did You Know?

Here are just a few tips to consider as you build your chronic care management (CCM) plan:

  • Phone calls are not required to meet minimum monthly time.
  • Time may not be carried over to the next month.
  • Billing is not required every month.
  • Service does not have to be in-house, but the provider must be accessible.
  • You can bill transitional care management and CCM in the same period if the work does not overlap.
  • Manual time tracking takes too much admin time. Always use a third-party application.
  • Those delivering outsourced care management get paid, but the billing provider is responsible for any audits.
  • Team members are required to provide services to be clinically integrated.
  • If a physician personally performs clinical staff activities, their time may be counted toward the required clinical staff time to meet the elements of a code.

Let’s Break It Down

The following minimum requirements must be met to bill Medicare for CCM.

 CCMComplex CCM
Minutes in a calendar month2060
Consentxx
Two or more chronic conditions expected to last 12 months or longer or until the patient’s deathxx
Non-face-to-face team carexx
A developed care planxx
Work performed by anyone on the clinical teamx99487
Work performed by a physician or other QHP 99491
Moderate- or high-level medical decision making x

There are lots of behind-the-scenes activities that are appropriate for billing care management. Here is a list of some appropriate activities:

  • Create or update care plans
  • Perform tasks in support of the care plan
  • Mine consult notes; follow up with patients
  • Reconcile medications
  • Patient or family phone calls
  • Administrative tasks (e.g., charting) by clinical staff

Never bill for care management when:

  • You have activities that are clearly overlapping with other evaluation and management services
  • You have not gotten written or verbal consent
  • You don’t have a care plan in place

Tip: Start slow and work your way up. Don’t enroll every patient who is eligible. Begin with a few patients and iron out the wrinkles before implementing a comprehensive program.

Getting Paid

Use the following codes when coding and billing CCM services:

99490   Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

+99439           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)

In the 2021 Medicare Physician Fee Schedule final rule, CMS instructs coders to use new CPT® code 99439 in place of HCPCS Level II code G2058. Note that 99439 may only be reported twice per calendar month for a maximum of 60 minutes total time and may be billed concurrently with transitional care management codes 99495–99496 when reasonable and necessary.

Based on the documented time spent, use this table to decide which CCM codes to bill.

Total Duration of Staff Care Management ServicesCCM
Less than 20 minutesNot reported separately
20 to 39 minutes99490 x 1
40 to 59 minutes99490 x 1 and +99439 x 1
60 minutes or more99490 x 1 and +99439 x 2

Use the following codes when coding and billing complex CCM services:

99487   Complex chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, moderate or high complexity medical decision making; first 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 directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

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

G0506   Comprehensive assessment of and care planning for patients requiring chronic care management services

Bill complex CCM codes 99487 and +99489 based on time as shown in this table.

Total Duration of Staff Care Management ServicesComplex CCM
Less than 60 minutesNot reported separately
60 to 89 minutes99487 x 1
90 to 119 minutes99487 x 1 and +99489 x 1
120 minutes or more99487 x 1 and +99489 x # for each additional 30 minutes

When counting time to determine CCM or complex CCM coding make sure you don’t “double-dip,” Church warns. A 10-minute discussion about a case between two clinical staff members constitutes 10 minutes of time, not 20 minutes. Also remember that time the provider spends can count toward 99490, but clinical staff time does not count toward 99491.

Don’t confuse the following three codes for online digital evaluation and management services with CCM services:

99421   Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

99422              11-20 minutes

99423              21 or more minutes

The big difference between digital services and CCM is that digital services must be initiated by the patient. CPT® code 99421 is meant to be an episodic code rather than an overall chronic disease code.

Time to Get Started

Starting a CCM program requires preparation and a team mindset. It’s up to you and your entire care team to adopt this altered approach to patient care. Staff must be ready to educate themselves on the benefits of the program so they can explain them to patients in a way that encourages participation. Plan how best to get patients on board and then train your entire team. Develop a custom brochure that you can send home with patients. And above all, be ready to answer questions. The transition from episodic care to team care is in your hands.


Resources:

Chronic Care Management Services MLN Booklet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

https://www.aafp.org/news/practice-professional-issues/20181130ccmcoding.html

Lee Fifield

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Lee Fifield has a Bachelor of Science in communications from Ithaca College, Ithaca, New York, and has worked as a writer and editor for more than 15 years.

4 Responses to “Jumpstart Your Chronic Care Management Program”

  1. Tracy Lanferman says:

    Is there a billing/coding certification for chronic care management?
    I recently acquired my CPC through AAPC

  2. Renee Dustman says:

    AAPC does not have a credential for just chronic care management but out Certified Risk Adjustment Coder (CRC) covers coding chronic conditions.

    https://www.aapc.com/certification/crc/

  3. Megan Banks says:

    When you are billing 99490 and 99439, what if any are the appropriate modifiers? Especially in the case with 99490 x 1 and 99439 x 2, what modifier if any do you use on the second 99439 to show that it is not a duplicate? Having some trouble with Humana on denials for these services and not sure how to proceed. Any information would be greatly appreciated!

  4. Lee Fifield says:

    Megan, there is a table in the CPT book that describes this if you want to reference it. But no modifier is needed. Just add additional events up to 2.

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