With COVID-19 delaying many patients care, your chronic care patients need more care now than ever. New rules mean that it’s gotten easier to get paid for chronic care management — but only if you’re up to date on the numerous changes and requirements that CMS has recently put in place.
Reduced documentation requirements, new CPT code options, and clarified guidelines are just a few of the updates that lessen the burden for you to get paid for the time and effort it takes to care for your sickest patients. And with a new code series for patients with one chronic condition, you’ll have even more patients who qualify.
New Principal Care Management Codes Expand Patient Eligibility
In the past, providers could bill chronic care management services only for patients with two or more chronic conditions — but that’s changing.
Beginning on Jan. 1, 2020, providers can use one of the new principle care management codes to bill chronic care management services for patients with only one, high-risk chronic condition. CMS defines a “high risk” condition as one that:
- Is expected to last at least 3-12 months, or until the death of the patient
- May have led to a recent hospitalization
- Places the patient at significant risk of death, acute exacerbation, decompensation or functional decline
While CMS expects mostly specialists to use the new codes, there are no restrictions on what specialties can use them. Providers may choose one of the following new CPT codes to bill for time spent on principle care management services:
- G2064 (physician or other qualified health care provider time)
- G2065 (clinical staff time)
The required elements for principle care management billing are very similar to the requirements for comprehensive care management, with a few changes:
- Instead of requiring a comprehensive care plan, principle care management requires a disease-specific care plan, which may be more limited in scope.
- The provider billing for principle care management must document the communication and care coordination between all the patient’s providers in the patient record.
CMS Simplifies Chronic Care Management Care Plan with New Definition
A care plan is required for billing both chronic care management and principle care management services but knowing what counts as acceptable documentation can be confusing for providers and auditors.
In the 2020 Medicare Physician Fee Schedule Final Rule, CMS clarifies and simplifies the elements of a compliant care plan.
The most important thing to note is that, according to CMS, these elements are not a set of strict requirements that you must meet before billing for chronic care management services. A comprehensive care play typically includes — but is not limited to — the following elements:
- Problem list
- Expected outcome and prognosis
- Measurable treatment goals
- Cognitive and functional assessment
- Symptom management
- Planned interventions (providers no longer must identify the individuals responsible for each intervention)
- Medical management
- Environmental evaluation
- Caregiver assessment
- Interaction and coordination with outside resources and practitioners and providers (providers no longer must include a description of how these services are coordinated)
- Requirements for periodic review
- When applicable, revision of the care plan.
Chronic Care Management Coordination Documentation Is Simplified
With changing staff due to attrition and scheduling, updating an everchanging roster of coordinating staff was a logistical time drain. CMS eases this regulation in 2020 by indicating while it’s important to indicate the staff participating in the care, you don’t have to name each individual.
Combine Transitional & Chronic Care Management to Bump Reimbursement
Data shows that transitional care management decreases healthcare costs, reduces hospital readmission rates, and saves patient lives.
So why does CMS note that transitional care management services are underused compared with the number of beneficiaries who are eligible? Administrative burdens and low payment amounts could be to blame.
When CMS began paying for transitional care management services in 2013, they created a list of 57 HCPCS codes that they felt overlapped with transitional care management services, and thus, could not be billed concurrently with transitional care management codes.
Now, CMS has identified 16 of these codes that they no longer believe overlap. Starting in January 2020, you may bill the following codes concurrently with transitional care management codes — when medically necessity:
- 99358
- 99359
- 93792
- 93793
- 90960 – 90962
- 09066
- 90970
- 99091
- 99487
- 99489
- 99490 – 99491
- G0181
- G0182
CMS is also increasing the payment rate for the two transitional care management codes (99495, 99496).
Again, for a provider to bill the above codes along with the TCM codes, you must make sure that the documentation meets medical necessity requirements.
By breaking these code edits, CMS hopes to increase the appropriate use of transitional care management services, improving care for patients and your bottom line.
Online Training: You can get everything you need to take advantage of the new CMS chronic care management 2020 requirements in only 90 minutes. Read some of the tactics you’ll receive during this online training session presented by national coding expert, Kim Garner Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO.
