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Chronic Care Management CPT Code 99490: Increase Patient Care Quality and Take Advantage of a $27 Billion Dollar Market Opportunity for Physicians

In 2015, when CMS began the Chronic Care Management Program, CPT Code 99490, according to Medicare claims data, only about 275,000 unique Medicare beneficiaries received Chronic Care Management (CCM) services (CPT Code 99490) an average of 3 times each, totaling $37 million in allowable charges.  Unfortunately, those early participants accounted for less than ~1% of those Medicare beneficiaries that actually were potentially qualified to participate in the CCM Program. So, ~99% of the beneficiary market was still potentially available for program participation.

Given early results from the year before, in 2016, providers informed CMS that many barriers existed in providing CCM services and meeting all the requirements to bill for reimbursements.  Apparently, to their credit, CMS was aware and listening to feedback from the marketplace - in the 2017 Chronic Care Management updates, many of the provider barriers were addressed.

Highlights of the updates made to the 2017 Chronic Care Management CPT 99490 billing requirements are provided below. Read one or all of the highlighted topics:

New CPT Codes to Bill for Complex Chronic Conditions

In addition to the existing Chronic Care Management CPT Code 99490, providers may bill for an additional code to denote those beneficiaries with higher complexity chronic conditions – CPT Code 99487. A beneficiary may only be enrolled to receive either chronic care management services (CPT Code 99490) or complex chronic care management services (CPT Code 99487) in the given service period (calendar month), not both. The same service requirements will apply if a beneficiary is classified in either track with one exception – to bill CPT Code 99487, the clinical staff must provide 60 minutes of care management services involving complex care planning, instead of 20 minutes per calendar month as required to bill for CPT Code 99490.

Another new code, CPT Code 99489 has also been created by CMS to report clinical staff time and care provided in 30 minute increments in each calendar month above the required 60 minutes for those CCM program members classified as complex (CPT Code 99487).

Lastly, Code GPP7 is an add-on code to couple with billing for the face-to-face provider visits when comprehensive assessment and care planning by the physician or other qualified health care professional is provided to patients requiring chronic care management services.

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Initiating Visit Requirement for Chronic Care Management Enrollment Revised

As the CCM billing requirement stood in 2015 and 2016, to enroll a beneficiary to receive Chronic Care Management Services, an initiating visit must take place during an annual wellness (A/W), evaluation and management (E/M) or initial preventative physical exam (IPPE) visit.  In 2017, this requirement was updated to mandate that the initiating visit is ONLY for new patients or those patients who have not been seen in over a year instead of all beneficiaries receiving CCM services.

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Chronic Care Management Beneficiary Consent

In addition to the updated requirements of the initiating visit, CMS adjusted the requirements of the beneficiary consent as a prerequisite for Chronic Care Management billing in 2017.  While CMS still maintains that the billing practitioners inform the beneficiaries of the required information, they now no longer require written consent as a condition to begin chronic care management services -  now the conversation between patient and provider as well as whether the beneficiary accepted or declined these services can simply be noted in the medical record.

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24/7 Access to Care Redefined

The 24/7 access to care management services requirement language as we knew it 2015 and 2016 is redefined for 2017 Chronic Care Management. The new definition states that the scope of service element would be to provide 24/7 access to physicians, other qualified health care professionals or clinical staff and patient-caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week. It requires health professional to be accessible to address all urgent needs, not just urgent needs related to their chronic conditions. Also notable, the requirement for access to the patients' electronic care plan 24/7 is no longer a requirement – as long as it is shared in a timely manner (according to the ruling that may include fax transmissions).

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We Are Here to Help You Deliver Improved Care and Grow Your Practice Revenue ​

CCM offers a tremendous opportunity for providers to get compensated for the extra care they provide.  Our comprehensive approach assists providers in navigating each step-by-step process to meet all billing requirements for Chronic Care Management Services. To learn more about the CMS 2017 updates to the Chronic Care Management requirements, please call or email us today - eqhealth@eqhs.org or 800.720.2578. Click here to download our eQGuide to Chronic Care Management.

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