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Navigating Chronic Care Management (CCM) Reimbursement: Key Insights

Chronic care management (CCM) services significantly enhance the quality of care for patients with chronic conditions, improving health outcomes and reducing overall costs. However, the reimbursement process for CCM can be intricate and challenging. To help clarify, here are answers to some frequently asked questions about CCM reimbursement.

What is Chronic Care Management?

Chronic Care Management (CCM) services, as defined by the Centers for Medicare & Medicaid Services (CMS), are designed to enhance care quality for Medicare beneficiaries with two or more chronic conditions. CCM involves extensive care coordination outside of face-to-face visits, helping patients manage their chronic illnesses more effectively.

Who is Eligible for CCM Services?

Medicare beneficiaries with two or more chronic conditions expected to last at least 12 months, which place the patient at significant risk, are eligible for CCM services.

What Services are Included in CCM?

CCM encompasses non-face-to-face care services such as comprehensive care planning, medication management, coordination of care transitions, and communication with other healthcare professionals involved in the patient’s care.

How is CCM Reimbursed and What are the CCM CPT Codes?

Under the Physician Fee Schedule, Medicare reimburses for CCM services using specific CPT billing codes based on the complexity of the patient’s needs and the time spent on care coordination activities:

– CPT Code 99490 ($62)**: CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month.

– CPT Code 99439 ($47)**: Add-on code for CPT 99490; each additional 20 minutes of clinical staff time, per calendar month.

– CPT Code 99491 ($83)**: CCM services provided personally by a physician or other qualified health professional, at least 30 minutes, per calendar month.

– CPT Code 99437 ($59)**: Add-on code for CPT 99491; each additional 30 minutes, per calendar month.

– CPT Code 99487 ($132)**: Complex CCM, first 60 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month.

– CPT Code 99489 ($71)**: Add-on code for CPT 99487; each additional 30 minutes of clinical staff time, per calendar month.

Note: Reimbursement amounts are Medicare’s national non-facility averages and may vary by geography and payer.

Are There Specific Documentation Requirements for CCM?

Yes, providers must document the time spent on care coordination activities, patient consent to participate in CCM, and the development of a comprehensive care plan. Documentation should be thorough, accurate, and compliant with Medicare guidelines.

How Often Can CCM Services Be Provided?

CCM services can be provided to eligible patients once every calendar month. Providers should regularly reassess the patient’s eligibility and need for CCM services to ensure appropriate care coordination.

Do Billing Practitioners Need to See Their CCM Patients Face-to-Face?

Yes. For new patients or those not seen by the billing practitioner within a year prior to the start of CCM services, CCM must be initiated by the billing practitioner during a comprehensive evaluation and management visit (E/M visit), annual wellness visit (AWV), or initial preventive physical exam (IPPE).

Does Informed Consent for CCM Need to be Obtained During the Initial Visit?

The initiating visit for CCM and informed consent are separate requirements. While the initiating visit is an opportunity to obtain informed consent, it does not have to be obtained during this visit.

What Elements Should Be Included in the CCM Care Plan?

The comprehensive care plan typically includes, but is not limited to:

– Problem list

– Expected outcome and prognosis

– Measurable treatment goals

– Cognitive and functional assessment

– Symptom management

– Planned interventions

– Medical management

– Environmental evaluation

– Caregiver assessment

– Interaction and coordination with outside resources and practitioners

Can CCM Be Billed in Conjunction with RPM?

Yes, providers can bill for both CCM and Remote Patient Monitoring (RPM) services. However, the time spent on each service must be documented separately. Billing both CCM CPT Code 99490 and RPM CPT Code 99457 together requires at least 40 minutes of services: 20 minutes of CCM and 20 minutes of RPM.

Can CCM Services Be Provided by Non-Physician Practitioners?

Yes, CCM services can be provided by non-physician practitioners such as nurse practitioners, physician assistants, and clinical nurse specialists under a physician’s supervision.

What is the Definition of “Clinical Staff” for CCM Reimbursement?

According to the American Academy of Family Physicians (AAFP), a clinical staff member is someone who works under the supervision of a physician or other qualified healthcare professional and 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 service.

Can CCM Services Be Completely Delegated to Clinical Staff?

No. The billing practitioner must remain involved in CCM. While clinical staff can perform many CCM activities, certain elements, such as medical decision-making in complex CCM, require the practitioner’s direct involvement and cannot be subcontracted.

Can Clinical Staff Portions of CCM Be Performed by External Third-Party Companies?

Yes, provided all “incident to” and other billing rules are met. The billing practitioner must maintain oversight and clinical integration with the third-party provider to bill for CCM.

By understanding these guidelines and best practices, healthcare providers can effectively navigate CCM reimbursement, enhancing patient care while optimizing revenue. For more questions or information please reach out to a Lynk team member by emailing us at info@lynkhealthcare.com. 

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