Chronic Care Management Reimbursement: Why Aren't More Doctors Billing for It?

On January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) implemented a new reimbursement program for providers administering chronic care management (CCM) services. The program is designed to reimburse an average of $42 per month for each patient enrolled in a chronic care management program under a specific set of circumstances. Ultimately, the goal is to increase access to primary care services for chronically ill patients and help lower the financial strain on the healthcare system.

When the program first began, CMS anticipated many physicians would take advantage of this new source of revenue. But instead of jumping on the bandwagon, quite a few doctors have opted not to participate in billing for CCM services under CPT code 99490.

Why aren’t more physicians billing for services they were most likely already providing to their chronically ill patients? There are several obstacles to getting reimbursed that are preventing many doctors from taking advantage of the program. However, proposed changes to the program might help to reduce some of the confusion surrounding CPT 99490 and make it easier for doctors to get paid.

Why aren’t physicians billing CPT code 99490?

In a study published in the Annals of Internal Medicine in 2015, it was estimated that healthcare practices that billed CPT code 99490 for chronic care management services provided by non-physician healthcare practitioners (i.e. registered nurses, etc.) could expect an annual practice revenue increase of more than $75,000 if a minimum of 50 percent of eligible patients were enrolled in the program. That’s no small chunk of change, so there have to be serious reasons why doctors have chosen to leave it on the table.

· It’s complicated. One look at the FAQs page for Medicare’s CCM program shows you that billing CPT code 99490 is not as straight forward as you might think. There are many rules physicians have to abide by in order to qualify for reimbursement. CMS dictates everything from documentation using specific types of electronic health records (EHRs) to how many providers can bill for CCM services at the same time. Current requirements also mandate that all providers involved in an enrolled patient’s care must have access to the patient’s record and care plan 24/7, and that patients must be able to reach providers in a timely manner to be able to meet urgent care needs.

· It takes too much time. The administrative burden for participating in the program is not insignificant for doctors. According to a report published in the Annals of Family Medicine, primary care physicians are estimated to see an average of 2,300 patients every year in their practice, spending only about 15 minutes each day with each patient. Since billing for CCM services requires so much attention to detail, including documenting every minute of every phone call, text message, or email to the patient, many physicians find they don’t have enough time to make sure they’re adhering to all the program guidelines on top of providing prompt, effective care to their patients.

· Patients must give permission. Before any billing can be done, the patient must sign a consent form to start participating in the program. The form also grants permission for a doctor to bill CPT code 99490. According to CMS, there are no consent forms or templates available through the agency — each individual practice or provider must take the time to create a unique consent form that includes all necessary information. Also, patients are charged a copay each time a claim for CCM is submitted, making many reluctant to agree to participate – many had already been receiving chronic care management services from their doctors without any additional fees.

· There’s a technological burden to practices. Part of ensuring reimbursement from Medicare involves making sure the practice billing for service adheres to the technological requirements put in place by the agency. Certified EHR technology is specifically required by CMS in order to meet certain scope of service and billing qualifications. This places a burden on healthcare facilities, specifically more rural practices, who might not have the technology infrastructure in place. Adding a qualified EHR system to an existing practice is a huge financial commitment, and smaller facilities might not have the monetary resources necessary to install such systems.

· The “wait and see” approach. Physicians often wait to see if a new treatment or medication is truly effective before deciding to use it. The CCM program is no different, and many doctors are waiting to see if their colleagues have success with reimbursement before committing to participation in the program themselves.

Proposed CCM program changes for 2017

· Say goodbye to certified EHR requirements. One of the biggest challenges physicians face when billing for chronic care management is the implementation and management of the patient within CMS certified EHRs. One of the proposed rule changes for 2017 would remove the requirement to use a certified EHR system. Instead, providers would be able to share patient information and the patient care plan in whatever fashion they prefer, including fax or mail. This means that doctors who haven’t yet adopted an EHR system, either because the technology is not available in their rural location or because such systems are too expensive, will still be able to participate in the reimbursement program if they choose.

· No more need for a signed consent form. For 2017 it’s also recommended that patients no longer be required to physically sign a consent form in order to receive CCM services. Physicians will be able to bill CMS without having the patient sign any forms. Instead, the provider will simply document that the required information was explained to the patient, and that the patient either accepted or declined participation.

· New codes to help doctors collect more money. CMS has also suggested adding several new codes to help bill for CCM services, including:

1. CPT code 99487 for complex chronic care management of patients who have five or more chronic conditions and who take eight or more medications. The reimbursement for billing this code is estimated to be $92 per billing, per patient. To bill this code, the doctor would have to provide at least 60 minutes of telemedicine care per patient, per month.

2. CPT code 99489, which is an additional 30-minute code that can only be billed with CPT code 99487. This code would only be used for more complex patients who require more of the physician’s time.

3. G code GPP7 is proposed for physicians to bill for comprehensive assessment and care planning.

While these proposals are not inclusive of all the changes being recommended, they are perhaps the most important. It makes sense for doctors to bill for a service they are probably already providing — doctors should understand that while meeting the guidelines for reimbursement can be challenging, there is still a lot of money to be made from billing for your care of chronically ill patients – an estimated $332 per enrolled patient, per year. While the current rules for billing CCM services are puzzling, the proposed changes in 2017 could make the entire process much simpler and help add substantially more income to your practice.