What is CCM?
Recognizing the value Chronic Care Management (CCM) can deliver in improving health outcomes and reducing healthcare spending, the Centers for Medicare and Medicaid Services (CMS) adopted a new service code in January 2015. CPT Code 99490 reimburses physicians or other eligible healthcare professionals approximately $43 per patient per month (national average as of January 2017) for delivering at least 20 minutes of non face-to-face care coordination to eligible Medicare beneficiaries, with the following required elements:
How did the program change in 2017?
The success of CPT 99490 and demand from healthcare providers prompted new codes and more reimbursements for 2017, expanding the CCM program and providing these additional revenue opportunities:
CPT 99487 reimburses approximately $94 for 60 minutes of non-face-to-face care coordination and CPT 99489 reimburses approximately $47 for each additional 30 minutes.
Complex CCM shares common required service elements with CPT 99490 (now also referred to as non-complex CCM), but additionally requires the establishment or substantial revision of a comprehensive care plan, as well as moderate or high complexity medical decision making by the medical provider.
In what ways can CareSync support my CCM efforts?
The leading provider of software and services for Chronic Care Management, CareSync combines easy-to-use technology and 24/7/365 clinical services for healthcare organizations looking to outsource their CCM program. Our certified clinical team performs the required monthly services, your patients receive individualized, between-visit care, and you receive better data to help you provide value-based care while earning monthly recurring revenue.
CareSync exceeds Medicare’s requirements for CCM with patient-centered engagement solutions for CPT 99490. We also support practices in maximizing the opportunities afforded by new complex CCM codes 99487 and 99489, and add-on code G0506. If complex care takes up more of your valuable time, why shouldn’t you be getting paid for the additional work it requires.
Why should I use CareSync to provide this service? Can't I do it myself?
You could do it yourself, but do you want to? CPT 99490 requires providing the full scope of services each and every month to every one of the patients in your CCM program. This means spending a minimum of 20 minutes per month per patient providing non face-to-face care coordination. Finding the time, human resources, and technology to meet the requirements is already difficult, but it has been our experience that it actually takes quite a bit more time to fulfill the requirements every month. And as evidenced by CMS expanding the time and reimbursements for complex CCM cases, you can see they acknowledged there were discrepancies in how much time it was going to take to provide the appropriate care.
Instead, why not partner with the leader in providing Chronic Care Management services to patients?
Which patients/what chronic conditions are eligible?
Eligible Medicare beneficiaries include those with:
CMS maintains a Chronic Condition Warehouse with common chronic conditions listed to provide beneficiary, claims, and assessment data, but it did not limit the chronic conditions allowable under the CCM program. Chronic condition status is left to the discernment of the provider.
Which providers are eligible?
According to CMS: “Physicians and the following non-physician practitioners may bill CCM services: Certified Nurse Midwives; Clinical Nurse Specialists; Nurse Practitioners; and Physician Assistants. CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.”
While much of the time, primary care doctors coordinate care, there are plenty of eligible specialists who have taken on the role of CCM billing practitioner. For example, cardiologists are often the care coordinators for their patients with serious heart conditions.
Is a consent form required to enroll the patient?
Previously, a signed consent form was required to enroll a patient in CCM. New rules from CMS for 2017 allow the provider to choose to obtain either a verbal or written consent, provided it is documented in the medical record and that a face-to-face visit has been completed within the last 12 months. Either way, the provider must do the following:
When can the patient be enrolled?
Previously, CMS required the billing practitioner to furnish an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), or comprehensive evaluation and management visit to the patient prior to billing the CCM service, and to initiate the CCM service as part of this exam/visit. Now you can initiate CCM in the office or over the phone. Only new patients or patients who have not had a face-to-face visit within the past year are required to have an initiating visit for CCM services.
What if a patient is eligible, but doesn't have access to technology?
If your patient has access to technology, a great advantage will be having mobile access to their care plan, health summary, medical records, and valuable healthcare tools through the CareSync app. They can use it online through the Internet or download it (from the Apple Store or Google Play) to their smartphone or tablet and take important health information with them wherever they go. However, patients do not have to use the CareSync app to experience their CareSync membership benefits. In fact, we have found many patients continue or increase their utilization of their existing practice portal to review their care plan and medical documents.
Everything we do at CareSync is designed to engage the entire family and care team. While we have found that most of our silver users love their iPads and other devices, and quickly master these tools, we don't require them to use tools they don't want to use. We talk to them over the phone. They love the personal attention and the fact that we check up on them and their health conditions. Additionally, if a patient doesn't have access to email or a mobile device, we can invite the appropriate caregiver and close the loop electronically or by phone with that person. Our Health Assistants coordinate care with the entire team on behalf of the patient, so the reports and data are accurate and effective, even if the patient doesn't personally engage.
What if I enroll a patient, and he isn't qualified?
Let us know before the end of the period, and we'll remove the patient's plan without charge.
What if a patient wants to discontinue the service or switch to another CCM provider?
Only one provider may bill on any given month. The patient must notify CareSync in writing that they want to discontinue service, and the service will cease on the last day of that month.
How does CareSync meet the Medicare requirements for CPT 99490?
Here are the specific requirements, with the CareSync coverage of each:
Does CareSync do anything beyond Medicare's requirements?
We're glad you asked! These are just a few:
What sort of credentials do your Health Assistants have?
A Health Assistant is a clinical staff member that delivers CCM services and can include: Registered Nurses, Licensed Practical Nurses, Medical Assistants, Certified Nursing Assistants, Social Workers, and others.
Is your staff trained in HIPAA compliance?
Yes! Privacy and security are a key concern at CareSync. Everyone on the CareSync team is required to complete ongoing mandatory HIPAA and privacy training and everyone has signed the required HIPAA agreements.
Is CareSync a certified EHR?
CareSync is a collaborative, family-centered Personal Health Record. We use the same databases that certified EHRs use to create useful information from all the records we get - even the data from paper records is hand-keyed into discrete data fields. CMS requires that a certified EHR is used by the billing provider, so we will get a copy of your EHR's certification, and all the data will be available for you to receive into your EHR.
How do you comply with the CMS electronic communication requirements?
To be a third party provider of CCM, you have to have a level of integration, technology, and physician oversight. As a technology and care coordination company, CareSync has the technology and work process capabilities to integrate CCM workflows within practice operations, and can act as a true extension of the practice. We go beyond the minimum requirements to make sure each provider has access to all the information in a way that works best for the practice. The Care Plan and Health Summary are available digitally through EHR integration, automated or on-demand Blue Button download, or direct mail. We provide digital access to the patient's providers and caregivers with complimentary access to the CareSync platform, and any member of the care team can also request a fax or paper copy of the digital Care Plan. Click for more information on our Blue Button feature.
Is there a time when a patient covered by CCM is not eligible for the service?
Yes. As sourced from CMS documentation as of June 2017, billing restrictions include:
What if I have a patient in one of the above situations, such as a Transitional Care Management period?
You can't bill CCM services during the 30-day TCM period, but our service capabilities can help you meet the TCM requirements, including the 30-day care coordination required period.
What are the required elements for billing CPT 99490?
"Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, 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." (Source: CMS, current as of 1/5/17)
What insurance plans will pay CPT 99490?
Traditional Medicare, select Medicare Advantage plans, and a growing number of commercial and Medicaid plans. Many secondary insurers also contribute to the patient responsibility.
What is the expected payment?
The average reimbursement is about $43 (national average as of January 2017). The payment amount is subject to geographical adjustments, but you can get a good idea of what your reimbursement in your area will be with the CareSync Revenue Calculator. Click here, choose your region, and add your eligible Medicare lives estimate for your practice.
How are the care coordination minutes tracked?
CareSync care coordination technology tracks the minutes for each patient-related activity we perform, and the totals are included in your monthly billing report. Note: Every patient-related billable event is tracked and the timed events are available in case of an audit.
Is my patient responsible for any payment?
The same as any other billable code under Medicare, the patient is responsible for deductibles, copayments, and remainder amounts according to the patient's insurance agreement. CPT 99490 and complex CCM codes are not exempt from cost-sharing rules unfortunately, so Medicare Part B patients with no secondary coverage will be responsible for about $8/month, but keep in mind that it does vary. The intent of the code is to reduce costs for all parties, including the patient. Better coordination means fewer visits, which in turn reduces the patient's overall out-of-pocket expenses.
What are the billing details?
Turn to Frequently Asked Questions about Physician Billing for Chronic Care Management Services from CMS. Note: As part of our service, CareSync has billing specialists available to answer questions and provide guidance to your staff.