In 2016, Medicare added chronic care management (CCM, 99490) to its list of reimbursable codes. Starting Jan. 1, the agency is adding complex CCM services (99487-99489) to that list as well. But there are specific rules you must follow to get the payment you deserve.

Most likely, you’re already providing these much needed extra services for your patients. The problem has been that, up until now, the payment for CCM code 99490 only reimburses for 20 minutes of time — considering these are frequently your sickest patients, this usually just doesn’t cover the time and effort involved. This all changes in 2017 when Medicare starts paying for the complex CCM codes to help compensate you more accurately for the extended time it takes to provide complex CCM. But you must comply with their requirements to get paid.

Like regular CCM, you can bill complex CCM codes monthly. The new codes include all the same conditions as the regular CCM code does. To report codes 99487 and 99489, however, you must also do the following:

• Establish or substantially revise a comprehensive care plan;
• Address medical, functional, and/or psychological problems requiring moderate- or high-complexity medical decision-making; and
• At least 60 minutes of clinical staff care management services under the physician’s (or other qualified health professional’s) direction.

Note: A minimal alteration to the care plan, such as prescribing an alternate medication or ordering a treatment modality adjustment, does not qualify as “substantially revise,” according to CPT®.

In addition to the above items, you must be able to categorize your patient as “complex.”  Generally, these patients have two or more chronic conditions or episodic health conditions that will last at least 12 months. In addition, CPT lists the following as potential markers that indicate complex CCM services:

• Multiple illnesses
• Multiple medication use (usually three or more drugs, as well as therapeutic interventions like physical or occupational therapy)
• Inability to perform activities of daily living and/or cognitive impairment resulting in poor adherence to the treatment plan without substantial caregiver assistance
• Repeat admissions or emergency department visits
• Need to coordinate multiple specialties and services
• Psychiatric and other medical comorbidities — such as dementia and chronic obstructive pulmonary disease or substance abuse and diabetes — that complicate care
• Social support requirements or difficulty with access to care.

Coding Complex CCM

As with regular CCM, the codes for complex CCM are based on how much time you commit to a patient’s chronic care during a calendar month. Code 99487 represents the first 60 minutes of complex CCM services for the month, and +99489 is for each additional 30 minutes.

If you provide less than 60 minutes of complex CCM, you cannot report 99487 — although this will likely qualify for 99490. In fact, here’s how CPT breaks down the timing for complex CCM:

EXAMPLE: You provide complex CCM services for an elderly patient with dementia, chronic hypertension, diabetes and macular degeneration who is on insulin, blood thinners, and memory therapy. You also coordinate care with the patient’s ophthalmologist and physical therapist, among other care management efforts. During the month, you spend the following time:

• 30 minutes — Reviewing and altering the patient’s care plan to accommodate unstable blood glucose lab results
• 10 minutes — Staff telephone conversation with caregiver to explain new insulin dosing and physical therapy regimen
• 7 minutes — Conversation with ophthalmologist regarding patient’s macular degeneration treatment decision and timing of therapy
• 15 minutes — Nurse telephone conversation with patient regarding diet and suggested meal alternatives to address diabetes
• 4 minutes weekly — Nurse time with patient and caregiver after weekly in-office blood glucose testing to review results.

The resulting total complex CCM time is 78 minutes. That means you should report 99487 for the month to represent the services provided for the patient.

Take Aways

• Medicare will pay for complex CCM services (99487-99489) in 2017.
• Reserve complex CCM services for your sickest patients, which means it’s more than a simple medication or therapy change.
• Track all your time — both physician and clinical support staff — so that you can report complex CCM appropriately.