January 1, 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (MPFS) and the Outpatient Prospective Payment System (OPPS) for the AMA’s CPT code 99490 for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions. These services have been overlooked by many hospitals as a “professional-only” service, thus missing a revenue opportunity (hard to find in the world of Medicare payments). Although CMS does not recognize CCM as an RHC or FQHC service, an RHC or FQHC may have the opportunity to bill for CCM on the Medicare Physician Fee Schedule, provided it satisfies the applicable billing requirements for non-RHC/non-FQHC services.
CMS pays the following for CCM services:
- PPS Hospitals: 2016 Medicare APC Rate
- CAH Hospitals: 2016 Outpatient Interim Rate
- RHCs: 2016 Average National Non-Facility MPFS
CPT Code 99490 is defined as 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, 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.
A “clinical staff” member is a person who works under the supervision of a physician 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 who does not individually report that professional service. Other policies may also affect who may report specific services. CMS has given an example of types of clinical staff in the Federal Register/Vol. 79, No. 219/Thursday, November 13, 2014/Rules and Regulations 67711, as “RN/LPN/MTA.” Although there are no other references for other types of authorized staff, e.g., medical social workers, there are also no defined excluded individuals, with the exception of clinical psychologists, podiatrists, or dentists. These practitioners cannot furnish or bill for CCM services.
Finally, CMS states that “services provided directly by an appropriate physician or non-physician practitioner, or by clinical staff incident to the billing physician or non-physician practitioner, count toward the minimum amount of service time required to bill the CCM service (20 minutes per calendar month).”
Consequently, qualified hospital and clinic staff are integral to the delivery of CCM services. Since most hospitals are already performing some or all of the CCM requirements for their outpatients, enhancing their existing policies and procedures to incorporate the CMS CCM-required processes should not be too burdensome.
A complete description of the CMS requirements for CCM services can be found at the Medicare Learning Network® “Chronic Care Management Services” Fact Sheet:
Author: Jeanne Chapdelaine, Director