A Step-by-Step Guide toImplementing Chronic CareManagement for CPT 99490W E S T H E A LT H C A R E

Chronic Care Management OverviewChronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicarebeneficiaries who have two or more significant chronic conditions. In addition to office visits and otherface-to face encounters, which must be billed separately, these services include communication withthe patient and other treating health professionals for care coordination (both electronically and byphone), medication management, and providing accessibility 24 hours a day to patients and othertreating physicians or clinical staff. The creation and revision of electronic care plans is also a keycomponent of CCM. The designated CCM clinician (MD, PA, NP) must establish, implement, revise, or monitor andmanage an electronic care plan that addresses the physical, mental, cognitive, psychosocial,functional, and environmental needs of the patient as well as maintain an inventory of resourcesand supports that the patient needs. Thus, the practice must use a certified EHR to bill the CCMcode. Only one clinician can bill for CCM services for a particular patient. Therefore, it may be necessaryto coordinate with sub-specialists who may be providing a significant amount of care and treatmentfor one or more of the patient’s conditions. Since many patients have multiple physicians, it isimportant for patients to understand that only one physician will be able to bill for CCM services.The CCM code is generally intended for use by the clinician who is providing the majority of thecoordination services, which is typically the primary care physician. However, certain specialists maybe able to provide the services needed to qualify to bill the CCM code — but never in the same monthas the primary care physician.

Key DefinitionsELIGIBLE PROFESSIONAL (EP)CONTACT-BASED CAREThe CCM code can only be billed by a physician, advancedTo count the time towards the required 20 minutes ofpractice registered nurse, clinical nurse specialist, ornon-face-to-face care, the care must be “contact initiated.”physician assistant.This could be patient-doctor, patient-nurse, doctor-doctor,pharmacy-doctor, lab-doctor, or other contact regardingCHRONIC CONDITIONor by the patient via phone or electronic communication.CPT states that patients must have “2 chronic continuous orGeneral planning time or care coordination does not countepisodic health conditions that are expected to last at leastunless it is initiated based on a contact and/or results in12 months, or until the death of the patient, and that placea patient or patient-related contact. For example, if thethe patient at significant risk of death, acute exacerbation/pharmacist calls the physician’s office because the patientdecompensation, or functional decline.”reported a rash, this time counts. If the physician’s officespends time running reports of all participants who are dueCOMPREHENSIVE CARE PLANThis is an electronic summary of the physical, mental,cognitive, psychosocial, functional, and environmentalassessments, including: recommended preventivecare services; medication reconciliation with review ofadherence and potential interactions oversight of patientfor a flu shot or an A1C check, the time does not count.When a clinician calls and speaks to the patient and thencoordinates care, the time counts. In-person visits, includinggroup visits, do not count toward the CCM code.CERTIFIED EHR TECHNOLOGYself-management of medications; an inventory of clinicians,For, the CCM code must be provided by a certifiedresources, and supports specific to the patient, includingEHR that satisfies either the or edition of thehow the services of agencies or specialists unconnected tocertification criteria for the EHR Incentive Programs withthe designated physician’s practice will be coordinated; andthe following core technology capabilities:the assurance of care appropriate for the patient’s choices medications, and medication allergies.and values. CLINICAL STAFFLicensed clinical staff members (including APRN, PA, RN,LSCSW, LPN, clinical pharmacists, and “medical technicalassistants” or CMAs) who are directly employed by theclinician (or the clinician’s practice) or a contracted thirdparty and whose CCM services are generally supervised bythe clinician, whether provided during or after hours. Thusthe “incident to” rules do not necessarily require that theclinician be on the premises providing direct supervision.Structured recording of demographics, problems,Creation of a summary of care record that can bemaintained and accessed at any time.

Billing Requirements Under CPT code 99490, the average reimbursement is 42.60, adjusted based on geography. Only one clinician can furnish and be paid for CCM services during a calendar month. The clinician who is providing theprimary care to the patient is the one who can bill. Usually this will be the primary care physician, but some specialistsmay be serving as the patient’s primary care physician. Copayments (coinsurance and deductibles) DO apply. The following codes cannot be billed during the same month as CCM(CPT 99490): Transition Care Management (TCM) – CPT 99495 and 99496 Home Healthcare Supervision – HCPCS G0181 Hospice Care Supervision – HCPCS G9182 Certain ESRD services – CPT 90951-90970To find payment information fora specific geographic location,access the Medicare PFS Look-Uptool on the CMS or-ServicePayment/PFSlookupIf other E&M; or procedural services are provided, those services will be billed as appropriate. That time can NOT becounted toward the 20 minutes for CCM. If time — such as from a phone call — leads to an office visit resulting in anE&M; charge, that time would be included in the billed office visit, NOT the CCM time.Patient Consent The practice must have the patient’s written consent in order to bill forCCM services. Document patient consent, if they declined to participate, or indicatedA sample consent form is providedat the end of this document.participation elsewhere (and if so, with whom).Documentation Document 20 minutes of non-face-to-face clinical staff time. A practice can insource or outsource the delivery of CCM services for its patients. In either case, the practice willneed to establish a consistent system of documentation based on its own physical, staffing, and EHR configurations.Consideration should include documentation of care provided by both internal and external individuals (such as for callcoverage), who and how care will be documented in the record, and how to document time spent delivering variousaspects of care and care coordination. It is possible that there will not be a CCM code billed for every patient everymonth, since some months may not generate 20 minutes of care coordination. If after hours care is provided by a clinician who is not part of the practice, such as for call coverage, that individual musthave access to the electronic care plan (other than by facsimile). The care plan may be accessed via a secure portal,a hospital platform, a web-based care management application, a health information exchange, or an EHR to EHRinterface. Services can be provided “incident-to” the designated clinician if the CCM services are provided by licensed clinical staffemployed by the clinician or practice who are under the general, not necessarily the direct, supervision of the designatedclinician. The normal “incident-to” documentation requirements apply. Contracted clinicians count as long as they have access 24/7 to the patient’s electronic record and are under thegeneral supervision of the CCM physician or “eligible practitioner.”

Four Steps to Implementingthe CCM Code1IDENTIFY & RECRUIT ELIGIBLE PATIENTS Use the EHR to search for patients who have 2When just starting out with implementing a CCMor more chronic conditions. Run reports sorted byprogram, you might focus on a small number ofphysician. Each practice can then review the reportspecific diagnoses, such as diabetes, COPD, CVD,and eliminate individuals who do not appear to be aand/or A-fib.good fit for the CCM program. Contact the patient through an outreach campaignThe patient must have 2 or more chronic conditionsor discuss the CCM program during a regularlythat have the following required elements:scheduled visit to drive education and awareness expected to last at least 12 months or until death. about the importance of managing chronic disease.Multiple (2 or more) chronic conditions that are Consider a dedicated phone line that would bePlace the patient at significant risk of death,answered by staff with specific knowledge of theacute exacerbation/decompensation, orCCM program. This line can be forwarded to on-callfunctional decline.clinician after hours.When just starting out with implementing a CCM program, you mightfocus on a small number of specific diagnoses, such as diabetes,COPD, CVD, and/or A-fib.2EDUCATE & ENROLL Educate patients and encourage them to participate Explain the monthly scheduled nurseusing an invitation letter combined with a writtenassessment visit, which should be treated like aconsent to participate. A sample is attached at theregular visit, even though it will occur by phone.end of this document. Explain how and when the bills will be generatedExplain the value of the program, how theand what the patient’s obligation is for paymentprogram works, and the fact they can decline,of coinsurance and deductibles.transfer, or terminate at any time. Review the participation agreement with the patientProvide information on how they can terminateand validate their understanding by obtaining theiror transfer.signature on the consent form.Authorization of electronic communication of Record in the electronic chart that CCM wasmedical information with other clinicians (asexplained and written consent obtained to acceptallowed by state and local rules and regulations).or decline services, from whom (name of clinician),Provide the designated physician’s name as wellreceive electronic care plan, and of the right to stopas the name of the CCM nurse.CCM services at any time.

3ENGAGE & ACTIVATE Provide care management for chronic conditions, their comprehensive care plan.including: Provide systematic assessment of the patient’sEnsure timely receipt of all recommendedparticipating patients (or their designatedpreventive care services.caregiver) to join and become familiar with use ofPerform medication reconciliation with review ofthe portal.Create a patient-centered care plan based on a Set up a system that can keep track of timeand environmental (re)assessment and an inventoryincluding: As appropriate, share the comprehensive care planBILL FOR REIMBURSEMENTValidate that the requirements were met for eachpatient each month. Document the time spentspent on non-face-to-face services provided,Using the patient portal is a low cost wayto deliver the care plan, so encourage allparticipating patients (or their designatedcaregiver) to join and become familiarwith use of the portal. physical, mental, cognitive, psychosocial, functionalwith other clinicians and providers.4Using the patient portal is a low cost wayto deliver the care plan, so encourage allof resources and supports. medical, functional, and psychosocial needs.adherence and potential interaction. Provide patient with the written or electronic copy ofSubmit CCM billing under CPT code 99490.Phone calls and email communication withpatient. Time spent coordinating care (by phone orother electronic communication) with otherclinicians, facilities, community resources,and caregivers. Time spent on prescription management andmedication reconciliation.

ResourcesFREQUENTLY ASKED QUESTIONS ABOUT BILLING MEDICARE FOR CHRONIC CAREMANAGEMENT SERVICESCCM must be initiated by the billing practitioner during a comprehensive Evaluation & Management(E/M) visit, annual wellness visit (AWV) or initial preventive physical exam (IPPE). This face-to-facevisit is not part of the CCM service and can be separately billed to the PFS, but is required before CCMservices can be provided directly or under other ds/Payment for CCM Services FAQ.pdfCHRONIC CARE MANAGEMENT SERVICES FACT SHEETThe CCM scope of service is extensive and includes structured data recording, the development of apatient-centered care plan, and 24/7 access to care management ads/ChronicCareManagement.pdfCHRONIC CONDITIONS AMONG MEDICARE BENEFICIARIES CHARTBOOKThe majority of Medicare beneficiaries suffer from multiple chronic conditions, including high bloodpressure, depression, heart disease, and diabetes. This increasing prevalence has expanded the needfor high-quality, coordinated care in order to measurably improve patient health nicConditions/Chartbook.htmlCHRONIC CONDITIONS OVERVIEWThe Centers for Medicare & Medicaid Services (CMS) analyzes the chronic conditions and their impacton the healthcare system. This information can be used to identify high-risk patients, and informproviders on how to approach and manage these cConditionsABOUT WEST HEALTHCAREWest helps healthcare providers, payers, employers, pharmacy organizations, and ACOs optimize communications, drive betterpatient activation, and lower the overall cost of delivering care. Whether you want to increase immunization and screening rates,reduce hospital re-admissions for patients with chronic disease, or improve the patient experience and operational efficiency inyour patie