What you need to know about chronic care management

Q: Our practice was recently researching the chronic care management services and codes. How can we use these codes to maximize our physician reimbursement?

A: Chronic care management services would help your physician or non-physician practitioners’ (NPP) reimbursement because it is a way to be reimbursed for some of the services they are already providing, and includes the work that the clinical staff is doing as well. The Centers for Medicare and Medicaid Services has established a physician fee schedule amount for facility ($32.89) and non-facility ($42.91) pricing.

The CPT description is:

99490: 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.

Note that chronic care management services of less than 20 minutes in duration, in a calendar month, are not reported separately.

In addition to physicians and NPPs, clinical staff can perform the services acting under general supervision, when incident-to-requirements are met. This is true regardless of whether the individual is an employee, leased employee, or independent contractor of the physician or other practitioner, or the same entity that employs or contracts with the physician or other practitioner and meets any applicable requirements to provide the services, including licensure, imposed by the state in which services are being furnished.

An important change for 2015 is that the services can be provided under general rather than direct supervision. According to 42 CFR 410.32(b)(3)(i), general supervision is when “the procedure or service is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.”

Additionally, the supervising physician or other practitioner does not have to be in the same office suite as the person providing the service when services are provided outside of normal business hours, and the supervising physician or other practitioner need not be the same physician or other practitioner that determined the care plan.

Patient notification

Educating patients on their rights and responsibilities under chronic care management are important.

Under the program, patients and caregivers have enhanced opportunities to communicate with each other regarding the patient’s care. First, you must inform the patient of the availability of chronic care services and obtain written agreement to provide the services, along with authorization from the patient to share the patient’s medical information with other practitioners through electronic methods.

It’s important to document in the patient’s record that all of the elements of chronic care management were explained to the patient, to note the patient’s decision to accept or decline the service, and that the patient received a copy of the care plan.

It’s important to stress that effective chronic care management can be accomplished only through regular monitoring of the patient’s health status, and through frequent communication and exchanges of information with the patient and the patient’s other healthcare providers.

Physicians who use remote monitoring may count the time spent reviewing data towards the monthly time for chronic care services, but not the total time the patient spends using the monitoring device.

NEXT: Scope of services

Scope of services

To bill successfully for chronic care management services, the following services must be provided.

24/7 access

The provision of 24-hour-a-day, 7-day-a-week access to address the patient’s acute chronic care needs. This means that the patient must be provided with means to make timely contact with healthcare providers in the practice.

Continuity of care

Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.

The care plan, part 1

The care plain should include:

• systematic assessment of the patient’s medical, functional, and psychosocial needs;

• system-based approaches to ensure timely receipt of all recommended preventive care services;

• medication reconciliation with review of adherence and potential interactions; and

• oversight of patient self-management of medications.

The care plan, part 2

The patient-centered care plan document is intended to ensure that care is provided in a way that is congruent with patient’s choices and values. The care plan must cover all patient health issues, and typically includes the following elements:

• problem list;

• expected outcome and prognosis;

• measurable treatment goals;

• symptom management;

• planned interventions;

• medication management;

• community/social services ordered;

• how the services of agencies and specialists unconnected to the billing practice will be directed/coordinated;

• identifying the individual responsible for each intervention;

• the requirements for periodic review, and when applicable, revision of the care plan; and

• the full list of problems, medications and medication allergies in the electronic health record must inform the care plan, care coordination and ongoing clinical care.

Care transitions

The management of care transitions is a vital part of chronic care management, and must include:

• referrals to other clinicians;

• follow-up after the patient’s visit to an emergency department;

• follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities;

• facilitating communication of relevant patient information through electronic exchange of a summary care record with other healthcare providers regarding these transitions;

• available qualified personnel to deliver transitional care services to the patient in a timely way so as to reduce the need for repeat visits to emergency departments and readmission to hospitals, skilled nursing facilities or other health care facilities; and

• coordination with home- and community-based clinical service providers required to support the patient’s psychosocial needs and functional deficits (communication to and from home and community based providers must be documented in the patient’s medical record).

The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.