Tuesday, November 10, 2015

Payment errors for chronic care management

As of January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) has created a new Current Procedural Terminology® (CPT®) code for chronic care management (CCM): 99490. First Coast’s data analysis reveals that providers are improperly billing this service. In response to these findings, First Coast will be implementing edits within the claim processing system to avoid improper payment for CCM services that do not meet CCM service guidelines.
This article reviews specific points that providers should consider regarding CCM guidelines, along with a link to a Medicare Learning Network® (MLN®) article that outlines the CCM guidelines in more detail.

Provider eligibility
• Only one provider may be paid for the CCM service for a given calendar month. CCM may be billed most frequently by primary care physicians, although specialty physicians who meet all of the billing requirements may bill the service
• CCM is not within the scope of certain practitioners
• Only clinical staff may provide CCM
• General supervision requirements apply to CCM services

Patient eligibility
• Patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline are eligible for the CCM service
• A provider must have seen a patient for either an annual wellness visit (AWV), an initial preventive physical examination (IPPE) or a comprehensive level of evaluation and management (E/M) visit prior to providing CCM
• Based on this examination, a provider may identify the need for CCM, and must document the patient’s acceptance and awareness of this arrangement along with additional specific points regarding CCM
• CCM must ensure 24-hour-a-day, 7-day-a-week access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s health record to address his or her urgent chronic care needs

CCM billing and documentation guidelines
• CCM cannot be billed in the same month as the encounter in which an initial determination for CCM is made
• CPT® code 99490 cannot be billed during the same calendar month as:
• CPT® codes 99495-99496 (transitional care management) or 90951-90970 (certain End-Stage Renal Disease services)
• Healthcare Common Procedure Coding System (HCPCS) codes G0181/G0182 (home health care supervision/hospice care supervision)
• CCM requires at least 20 minutes of clinical staff time directed by the practitioner to qualify for billing the service
• This time may accumulate throughout the month, and once the 20 minute requirement has been fulfilled, the related claim may be billed (i.e., at any time during the month)
• CMS requires the use of certified electronic health record (EHR) technology to satisfy certain CCM scope of service elements

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