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March 24, 2015

Chronic Care Management (CPT Code 99490)

CGS has received multiple questions regarding CPT code 99490 (Chronic Care Management). To assist you in determining whether you are submitting this code correctly and documenting your services appropriately, please refer to the following questions and answers:

  1. CPT for 99490 is defined as "clinical staff time directed by a physician or other Qualified Health Care Provider (QHCP)". Can you define what constitutes "clinical staff"? RN, LPN, Certified MA, pharmacist, etc.
    • Page 2 of the CMS Chronic Care Management (CCM) Fact SheetExternal PDF states: "Eligible practitioners must act within their State licensure, scope of practice, and Medicare statutory benefit. The CCM service may be billed most frequently by primary care physicians, although specialty physicians who meet all of the billing requirements may bill the service. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, therefore these practitioners cannot furnish or bill the service. However, CMS expects referral to or consultation with such physicians and practitioners by the billing provider to coordinate and manage care."
    • Please note: "Only one practitioner can furnish and be paid for the service during a calendar month."
  2. Is your expectation the same as noted in the introduction section of CPT?
    • Yes; additional rules and guidelines are available in the narrative section of the CPT manual. CGS follows these rules unless otherwise directed.
  3. Since this is a non-face-to-face code, does "incident to" apply, or will this be covered under general supervision?
  4. Do you have a list of recommended chronic conditions that supports the requirement for patients to be eligible?
    • As stated on page 2 of the CMS CCM Fact SheetExternal PDF: Examples of chronic conditions include, but are not limited to, the following:
      • Alzheimer's disease and related dementia;
      • Arthritis (osteoarthritis and rheumatoid);
      • Asthma;
      • Atrial fibrillation;
      • Autism spectrum disorders;
      • Cancer;
      • Chronic Obstructive Pulmonary Disease;
      • Depression;
      • Diabetes;
      • Heart failure;
      • Hypertension;
      • Ischemic heart disease;
      • Osteoporosis
    • Additional resources are located on page 10 of the CMS CCM Fact SheetExternal PDF.
    • Documentation in the patient's medical record should support that the patient's chronic conditions meet the standards per the CPT narrative; they must "place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline."
  5. The CCM code is per calendar month and the non-face-to-face work would be done throughout the month. What date of service will you require; last date of the month?
    • As stated on page 1 of the CMS CCM Fact SheetExternal PDF: Chronic care management services consist ofat least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
    • Page 9 of the CMS CCM Fact SheetExternal PDF states:  CPT code 99490 cannot be billed during the same calendar month as CPT codes 99495–99496 (Transitional Care Management), Healthcare Common Procedure Coding System (HCPCS) codes G0181/G0182 (home health care supervision/hospice care supervision), or CPT codes 90951–90970 (certain End-Stage Renal Disease services).  Also consult CPT instructions for additional codes that cannot be billed during the same service period as CPT code 99490. There may be additional restrictions on billing for practitioners participating in a CMS sponsored model or demonstration program.
    • Claims should be submitted with the date of service on which the 20-minute requirement was met.
  6. Since this is a timed code, would you expect to see start and stop times documented in order to support the 20 minutes?
    • Yes, time must be documented as either total time OR start/stop times.
  7. There is a requirement that patients be able to reach providers 24/7. Does an answering machine meet the expectation?
    • No. As stated on page 4 of the CMS CCM Fact SheetExternal PDF: Access to care is a key requirement in order to submit claims for chronic care management. Providers must "ensure 24-hour-a-day, 7 day-a-week access to care management services," and patients must have "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 chronic care needs." An answering machine does not meet this requirement.
  8. What is the definition of comprehensive, regarding the care plan?
    • As stated on page 5 of the CMS CCM Fact SheetExternal PDF: A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:
      • 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;
      • Schedule for periodic review and, when applicable, revision of the care plan.
    • Also, keep in mind if you have specific questions about appropriate coding that you cannot resolve on your own, the appropriate first step would be to review the HCPCS or CPT codes and/or the regulation governing payment for the year of service. Providers are expected to make appropriate coding decisions based on Medicare instructionsExternal PDF and other information available.

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