In January 2015, the Centers for Medicare & Medicaid Services (CMS) started a program to reimburse physicians for providing non-face-to-face care to patients with multiple chronic conditions—also known as chronic care management services, or CPT® code 99490. As of November 2016, only 513,000 Medicare beneficiaries have had a chronic care management claim,1 despite the tens of millions of Medicare beneficiaries expected to be eligible. Daunting billing requirements overshadowed the program’s positive intent and discouraged many physician practices from adopting it. CMS acknowledged the issues and made several changes for 2017 to help ease the burden and accelerate program use.
How CPT code 99490 has changed
To incentivize physicians to offer chronic care management services, CMS relaxed various service elements and billing requirements, and established new billing codes. Here are the top three changes and what they mean to physicians and patients.2
1. Relaxed service element requirements
- Initiating visit: Physicians no longer need face-to-face visits with existing patients who have been seen in the last year to enroll them in a chronic care management program. New patients or those who have not been seen in the last year must still have an initiating visit to enroll.
- 24/7 access to care and continuity of care: Around-the-clock access is now for urgent needs rather than urgent chronic care needs. The requirement for after-hours access to beneficiaries’ electronic care plans has been eliminated. Faxes now suffice as electronic transmission of clinical summaries and care plans.
- Beneficiary consent: Signed consent forms for chronic care management are no longer required. Physicians can obtain patients’ verbal or written consent as long they document it in the medical record. Documentation must also show the patient accepted services.
- Comprehensive care plan: Healthcare providers no longer have to give patients a written or electronic copy of their care plans before initiating chronic care management services. Providers may deliver the care plan to patients in the format of their choice.
- Care transition management: Standards for clinical summaries (now called, “continuity of care documents”) have been removed.
2. Complex chronic care management CPT codes
- On Jan. 1, 2017, CMS started to pay physician practices for complex chronic care management services under two new CPT codes: 99487 and 99489. These codes call for strict adherence to all chronic care management requirements under CPT code 99490, as well as these new requirements:
- Documented moderate or high complexity of medical decision-making
- Code 99487 for complex chronic care management with at least 60 minutes of clinical staff time per month (versus 20 minutes for regular chronic care management services under code 99490)
- Code 99489 is an add-on code for each additional 30 minutes of clinical staff time after the 60 minutes under 99487
- Codes 99490, 99487 and 99489 can only be reported once per calendar month and only by the provider who performed chronic care management services in that calendar month
3. New Medicare code G0506 for initiating visit
- CMS established a new add-on billing code, G0506. With chronic care management, a face-to-face initiating visit is required before services can be provided. Now through G0506, providers have a way to bill for additional work performed outside the usual effort, face-to-face assessment and care planning during the initiating visit, annual wellness visit (AWV) or initial preventive physical exam (IPPE). Code G0506 can be billed in addition to the evaluation and management (E/M), AWV or IPPE code, but it can be billed only once for each beneficiary.
- G0506 cannot be billed by a single practitioner on the same day as G0505 (cognition and functional assessment) or as an add-on for a behavioral health integration (BHI) initiating visit or BHI services.
2017-2018 chronic care management outlook
Relaxed service requirements for billing, and new codes for complex chronic care management will hopefully encourage more physicians to participate in the CMS program. The need for these services will only continue to grow as the population ages and commercial payers follow Medicare’s value-based reimbursement model.
CMS sees chronic care management as a viable path for physicians to value-based care, which can ultimately improve quality of care for patients and increase efficiencies. As noted in CMS’ final rule for 2017 Medicare Physician Fee Schedule payment policies, the agency is “doubling down” on its investment in chronic care management services to help keep patients healthier and out of hospitals and emergency rooms, and reward healthcare providers who perform this valuable work with new revenue.
Choose a strategic partner to help with your transition to value-based reimbursement
Even with less stringent requirements and new billing codes, chronic care management can be challenging for physician practices to administer on their own. Change Healthcare is a partner who is well-versed in value-based reimbursement. We can help speed up the transition and bring more revenue to the bottom line through our Care Coordination Advocate services.
Learn how our Care Coordination Advocate can help your practice improve quality care and increase value-based reimbursement.
1“Physician Groups Split on Chronic Care Pay in Medicare Rule,” by Andis Robeznieks, HFMA, Nov. 7, 2016
2“Chronic care management: Medicare increases payment and relaxes standards,” by Rick Hindmand and Isabelle Bibet-Kalinyak, McDonald Hopkins, Nov. 15, 2016
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