Chronic Care Management Services - Medicare Advantage

Policy No: 122
Originally Created: 03/01/2016
Section: Administrative
Last Reviewed: 12/01/2018
Last Revised: 12/01/2018
Approved: 12/06/2018
Effective: 01/01/2019

This policy applies to all contracted physicians, other health care professionals, hospitals and other facilities.

Definitions

Chronic Care Management (CCM)
Services that are non-face-to-face care management/coordination services to members that have multiple (two or more) chronic conditions.

Clinical Staff
A person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individual report that professional service.

Incident To
Services that are furnished incident to physician professional services in the physician's office (i.e. separate office suite or within an institution) or in a member's home.

Policy statement

For Medicare Advantage line of business, when medical necessity criteria is met, our health plan reimburses for chronic care management services.

Additional requirements include, but not limited to, the following:

Chronic Care Management (CCM) services are identified with Current Procedural Terminology(CPT®) codes 99487, 99489, 99490 and Healthcare Common Procedure Coding System (HCPCS) code G0506.

Only one clinical staff can bill and receive reimbursement for CCM services once per calendar month. Specifically, the member would be classified as eligible to receive either complex (99487/99489) or non-complex (99490) CCM during the given service period (per calendar month), not both, by one clinical staff.

Required elements for billing 99487 and 99489:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Establishment or substantial revision of a comprehensive care plan
  • Medical decision making is of moderate or high complexity
  • Allowed once per calendar month
  • 99487 is reported for complex chronic care management services requiring 60 minutes of clinical staff time directed by a physician or other qualified health care professional
  • 99489 is to be listed separately in addition to the primary procedure code (99487) and is to only be billed for each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional

Required elements for billing 99490:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the member at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored
  • Allowed once per calendar month
  • 99490 is reported for chronic care management services requiring at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional

Effective 01/01/2019 the Centers for Medicare & Medicaid Services (CMS) approved in the 2019 Medicare Physician Fee Schedule Final Rule new CPT code 99491 for the CMS Chronic Care Management Program.

  • 99491, Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, 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

G0506 - Comprehensive assessment of and care planning for patients requiring chronic care management services, is to be listed separately in addition to the primary care management service. This is an add-on code to be used with another evaluation and management (E&M) service (the chronic care management initiating visit Annual Wellness Visit/Initial Preventive Physical Examination AWV/IPPE or qualifying face-to-face E&M visit). It cannot be an add-on code for the behavioral health initiative (BHI) initiating visit or BHI services.

CCM Services for Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs).

  • G0511, rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month
  • G0512, Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month

Qualified clinical staff include:

  • Physicians
  • Certified Nurse Midwives (CNM)
  • Clinical Nurse Specialists (CNS)
  • Nurse Practitioners (NP)
  • Physician Assistants (PA)
  • Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs)
  • Hospitals (including critical access hospitals)

"Incident to" billing may be utilized for CCM services. Clinical staff are to follow the "incident to" billing requirements as defined by CMS.

Proper modifier 25 coding and billing guidelines, in addition to meeting medical necessity criteria, must be followed if billing for both E&M and CCM services on the same day for the same member by the same clinical staff. If coding and billing requirements for modifier 25 are not met, clinical staff time for CCM services cannot be counted on the same day as the E&M service.

Clinical staff are to follow the CMS CCM Scope of Service Elements and Billing Requirements. Information on these requirements are located on the CMS webpage Connected Care: The Chronic Care Management Resource under Health Care Professional Resources.

Additional Billing Requirements
CCM services cannot be billed during the same service period, except as previously noted by CMS, as:

  • 99080 (Preparation of special reports)
  • 99090 and 99091 (Remote patient monitoring)
  • G0181/G0182 (Home health care supervision/hospice care supervision)
  • 90951-90970 (End-Stage Renal Disease services)
  • 98960-98962, 99071, 99078 (Education and training)
  • 98969, 99444 (On-line medical evaluation)
  • 99324-99328, 99334-99337 (Domiciliary, rest home services)
  • 99339, 99340, 99374-99380 (Care plan oversight services)
  • 99341-99345, 99347-99350 (Home services)
  • 99358, 99359 (Prolonged services without direct patient contact)
  • 99363, 99364 (Anticoagulant management)
  • 99366, 99367, 99368 (Medical team conferences)
  • 99441-99443 (Telephone services)
  • 99495-99496 (Transitional care management)
  • 99605-99607 (Medication therapy management services)

CCM services will not be reimbursed:

  • For individuals located outside the United States

Telehealth/Telemedicine Services

Facility Billing Rules

  • Refer to the CMS Connected Care: The Chronic Care Management Resource webpage on CCM requirements for scope of service elements furnished to hospital outpatients under the Outpatient Prospective Payment System (OPPS)
  • The time spent providing CCM services to the member while he/she is not inpatient can be counted towards the minimum 20 minutes of service time that is required to bill for that month
  • For calendar year 2016 and subsequent years, hospitals are able to bill CCM services only when furnished to a member who has been either admitted to the hospital as an inpatient or has been registered outpatient of the hospital within the last 12 months and for whom the hospital furnished therapeutic services
  • If the place of service for CCM becomes the hospital outpatient department, it is assumed that the member has established a relationship with the hospital for CCM services
  • A provider-based outpatient department of a hospital is part of the hospital and therefore may bill for CCM services furnished to eligible members, provided that it meets all applicable requirements. A hospital-owned practice that is not provider-based to a hospital is not part of the hospital and, therefore, not eligible to bill for services under the OPPS; however, the clinical staff practicing in the hospital-owned practice may bill under the CMS Physician Fee Schedule for CCM services furnished to eligible members, provided all billing requirements are met
  • When a clinical staff furnishes CCM services in a hospital outpatient department to an eligible member, the clinical staff may bill CCM services using place of service 22 (outpatient hospital). Reimbursement to the clinical staff will be made at the CMS Physician Fee Schedule facility rate
  • As only one clinical staff is allowed to bill for CCM services during a calendar month service period, accordingly, only one hospital is allowed to bill and be paid for CCM services during a calendar month service period

References

Centers for Medicare & Medicaid Services (CMS). INC 909188 - Chronic Care Management Services, May 2015

Centers for Medicare & Medicaid Services (CMS) (11/23/2018). Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting Interoperability Program; Quality Payment Program—Extreme and Uncontrollable Circumstance Policy for the 2019 MIPS Payment Year; Provisions From the Medicare Shared Savings Program— Accountable Care Organizations—Pathways to Success; and Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder Under the Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. CMS-1693-F , p. 126 and 232–234.

Centers for Medicare & Medicaid Services (CMS) (11/03/2017). Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program Final Rule. CMS-1676-F (PDF) , p. 120 and 515-550.

Centers for Medicare & Medicaid Services (CMS) (11/15/2016). Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements Final Rule. CMS-1654-F (PDF) , p. 215-219, and 278-311.

Centers for Medicare & Medicaid Services (CMS) (11/30/2016). Chronic Care Management Services Webinar (PDF) . Delivering Coordinated Care through Chronic Care Management Services.

Centers for Medicare & Medicaid Services (CMS). Frequently Asked Questions about Billing Medicare for Chronic Care Management Services (PDF) .

Centers for Medicare & Medicaid Services (CMS). Chronic Care Management Services Changes for 2017 (PDF) .

Centers for Medicare & Medicaid Services (CMS) CMS MLN Matters # SE0441 - "Incident to" Services, April 2013

Centers for Medicare & Medicaid Services (CMS) Outpatient Prospective Payment System (OPPS) 2016 Final Rule (PDF) , Section C.

Centers for Medicare & Medicaid Services (CMS) Outpatient Prospective Payment System (OPPS) 2017 Final Rule (PDF) , Section D

Centers for Medicare & Medicaid Services (CMS) Telehealth/Telemedicine website

Current Procedural Terminology(CPT®) Manual, AMA, 2017. Accessed via Optum360 EncoderPro.com Professional

Cross References

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