Medicare Guidelines for Chronic Care Management Services

September 10, 2019

What are Chronic Care Management Services?

Chronic care management services refer to the chronic care services provided by medical professionals to Medicare beneficiaries with at least two chronic conditions. A disease or condition is chronic if it lasts a year or more, or requires ongoing medical attention, or limits daily life activities. Some examples of chronic conditions include diabetes, hypertension, depression and fibromyalgia.

As of January 1, 2015, Medicare began providing reimbursement to eligible practitioners for chronic care management services and since then has expanded reimbursement for chronic care management services that add support for complex conditions, or require more time. There are four specific reimbursement codes medical professional can use; They are not complicated to use, but do require guidelines for chronic care management services that need to be met in order to avoid denied claims.

Typical reimbursements are about $43 per patient; it’s no wonder that many medical practices have taken advantage of the opportunity to increase revenue each month; By simply correctly reporting chronic care management services that they had already been providing, practices have been making substantial financial gains due to the new reimbursement policy.

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What are the Medicare Guidelines for Chronic Care Management Services Reimbursement?

First things first, in order for medical practices to be reimbursed for chronic care management services, their patients must have

  1. At least two chronic health conditions that place the patient at significant risk of functional decline, decompensation, acute exacerbation, or death, and are expected to last at least 12 months or until the death of the patient.
  2. Medicare Part B coverage.
  3. An initiating visit for new patients or patients not seen within 1 year prior to the commencement of the chronic care management services.

Other Medicare Guidelines for Chronic Care Management Services

Time Requirements

Each Chronic Care Management code has specific time requirements:

  • CPT 99490 requires 20 minutes of chronic care management services from clinical staff directed by a physician or other qualified healthcare professional, per calendar month. 
  • CPT 99491 requires 30 minutes of chronic care management services, and 
  • CPT 99487 requires 60 minutes. 
  • Another code, CPT 99489, is used for billing of additional 30 minute intervals of chronic care management services.

Since Medicare acknowledges that most chronic care management services are typically provided outside of in-person visits, you can apply the time spent on your CCM patients when they aren’t in the office, like communicating with them via messaging or over the phone. You can also include the time spent coordinating care for the patient, and any time your clinical staff spends caring for the patient as well (note: CPT 99491 may only use time spent personally by the billing practitioner.) 

Documentation and Structured Recording of Patient Health Information

Time spent caring for the patient must be documented, and the patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology. 

Check out RevUp Chronic Care Management Services, to see how physicians can keep an interactive electronic record for their CCM patients.

Comprehensive Care Plan & Management Under the Supervision of a Qualified Physician or Non-Physician Provider

Medicare requires a comprehensive care plan for each chronic care patient. The plan must be electronic. Both the patient and caregiver must have a copy of the plan. The electronic plan must also be available in a timely fashion to anyone within or outside of the practice who is part of the patient’s care team.

According to Medicare, management of the Comprehensive Care Plan should have a(n)

  • Systematic assessment of each patient’s medical, functional, and psychosocial needs
  • System-based approaches to ensure timely receipt of all recommended preventive care services
  • Medication reconciliation with review of adherence and potential interactions
  • Oversight of patient self-management of medications

Only Physicians, Certified Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners and Physician Assistants are allowed to bill for chronic care management services.

24/7 Provider Accessibility

All chronic care management plans must allow for 24/7 access to physicians or other qualified health care professionals or clinical staff. In other words, in order to bill for CCM services, patients must be able to access their care team no matter the time of day or week, be it through secure online portal, telephone or video call. 

Continuity of Care

Chronic care management services must provide a continuity of care. The patient must have a designated physician or qualified medical professional with whom they can schedule successive routine appointments.

Enhanced Opportunities for Communication with Care Team

Medicare requires “enhanced opportunities” for the patient and any member of the patient’s care team to easily communicate with each other by telephone, secure messaging, secure Internet, or secure online portal. 

Advance Consent

According to Medicare, it’s necessary to obtain advance consent for chronic care management services before any billing. Consent, written or verbal, must be documented in the electronic medical record, and inform the patient of

  • What chronic care management services are available and how much they’ll cost.
  • Only one qualified medical professional can furnish and be paid for chronic care management services during a calendar month.
  • The right to end chronic care management services at any time.

Medicare Chronic Care Management Service Codes – A Great Opportunity for Medical Practices 

Medicare’s chronic care management codes are a symbol of recognition of the important work that medical professionals do in caring for the millions of Americans who live with chronic conditions. Medical practices now have the opportunity to be compensated for their work in providing chronic care management services. By applying these new chronic care management capabilities, many practices have been able to add substantial incremental revenue

Find Out How Quatris Healthco & RevUp Can Help Your Practice Boost Revenue With Chronic Care Management Initiatives.

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