Coding chronic care the right way

Q: How is “general” supervision different than “direct” supervision for chronic care management services?  Does this mean that a clinical staff member other than the physician can create the plan of care?

A:

 No, the incident-to guidelines still must be met, meaning the physician/practitioner is responsible for creating the plan of care.  This is clearly defined in the 2014 final rule, which can be found at Federal Register Final Rule 2014.  

CMS has defined general supervision as 1) the supervising physician does not have to be in the same office suite as the person providing the service when services are provided outside the normal business hours, and 2) the supervising physician need not be the same physician or other practitioner that determined the care plan.

The rule states: “Other than the exception to permit general supervision for clinical staff, the same requirements apply to CCM services furnished incident to a practitioner’s professional services as apply to other incident-to services.” 

A comprehensive care plan typically should include, but is not limited to:

• Problem list;

• Expected outcome and prognosis;

• Measurable treatment goals;

• Symptom management;

• Planned interventions and identification of the individuals responsible for each intervention;

• Medication management;

• Community/social services ordered;

• A description of how services of agencies and specialists outside the practice will be directed/coordinated; and

• Schedule for periodic review and, when applicable, revision of the care plan.  

Q:

What date of service should be used on the physician claim and when should the claim be submitted?

A: The service period for CPT 99490 is one calendar month, and CMS expects the billing physician/practitioner to continue furnishing services during a given month as applicable after the 20 minute time threshold to bill the service is met. 

However, practitioners may bill at the end of the service period or after completion of at least 20 minutes of qualifying services for the service period. So once the 20 minute threshold is met, the physician/practitioner may bill on that date instead of holding the claim until the end of the month.

Q:

When we are coding for diabetes mellitus and the patient has more than one complication, do we code all of them?  Which code takes precedence?  For example, we have a patient with type 2 diabetes with neuropathic arthropathy (E11.610) and a foot ulcer (E11.621).

A: You should code both conditions. ICD-10 guidelines instruct to “assign as many codes from [diabetes code] categories E08-E13 as needed to identify all of the associated conditions that the patient has.”

Your code order depends on the primary reason that the patient is being seen, unless payer policy dictates otherwise. Diabetes complication codes “should be sequenced based on the reason for a particular encounter.”