Providers faced with managing chronic care for an increasing number of patients outside of a traditional hospital setting need to know about the new CPT code 99490 introduced in 2015. This code is not a handy catch-all, however, as coders need to know which criteria pertaining to both provider and patient must be met to successfully utilize it for optimum reimbursement.

Chronic care defined:

The AMA publication CPT Assistant (October 2014) defines chronic care management services (CCM) as services provided for patients residing at home, in a rest home, domiciliary or assisted living center. The physician or other care professional is entrusted with the management and coordination of services for all conditions, including psychosocial and other basic needs and activities for daily living. Covered services may include:

• Establishing, revising, implementing as well as monitoring a care plan
• Coordinating care of other agencies or professionals
• Educating the patient and/ or caregivers about the patient’s condition, prognosis and care plan

Chronic care management basic medical coding criteria:   

For medical billing purposes chronic management services using 99490, the guidelines require:

1. The minimum time spent providing CCM services must be at least 20 minutes of clinical staff time as directed by a physician or other qualified heath provider in a calendar month. This time need not be contiguous and includes both direct contact and non-face-to-face time. Time below 20 minutes may not be reported as a separate activity. Activities include any or all of the following:
2. Chronic conditions which put the patient at risk of death, acute exacerbation/ decompensation, or functional decline. The terms “comprehensive care plan established, implemented, revised or monitored” are defined in the coding descriptor. 
3. Two or more chronic conditions expected to last either at least 12 months or until the death of the patient. Examples: congestive heart failure and diabetes.
4. Time spent revising, implementing and documenting the care plan as well educating the patient or other caregivers.
5. When two or more staff members meet about the patient, the time of only one will be counted.  Only one provider (who assumes the patient’s care management) can report as 99490 in any given month.
6. The provider who is billing for services is required to establish, implement, revise and
7. Interacting with the patient or family, caregivers, other care professionals and agencies.
8. Continually monitor the care plan as needed. This must be based on the physical, mental, environmental, social, cognitive and functional assessment of needs. Among additional inclusions are:

a. Measurable treatment goals,

b. Management of symptoms,

c. Planned interventions as well as individuals responsible for interventions,

d. Management of medications,

e. The ordering and coordinating of community or other services,

f. Periodic review of plan with revisions as indicated.

g. The Centers for Medicare and Medicaid Services (CMS) require that clinical staff CCM services be provided under the billing provider’s general supervision, meaning that services are under the provider’s direction but the provider’s presence is not required as they are performed.

h. You cannot bill for both CCM services and Medicare for transitional care management services (99495 and 99496) in the same month.

Conclusion

While these guidelines are fairly clear-cut, they entail a good deal of additional reporting, including management of care transitions, patient access to care management 24/7 and other regulations. To keep up with the latest coding regulations and ensure compliance with correct coding and other measures, consider working with a professional medical practice billing service. M–Scribe Technologies, LLC has been a leader in the medical billing and coding industry since 2003. Contact us today for a free analysis of your practice’s needs and to learn how you can save time and money as well as improve compliancy and reimbursement rates.

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