Update Notice: This information was updated for accuracy on May 19, 2021. This update reflects the 2021 CPT code changes for Chronic Care Management, specifically the replacement of code G2058 with code 99439. You’ll find this update in the “Facilitate Transitions of Care – Chronic Care Management Options” section below.
Whether it’s diabetes, arthritis, or heart disease, an increasing number of your patients are likely to have at least one chronic condition, especially as the Baby Boomer population ages. Over the past few years, CMS has expanded coverage for chronic care management.
The catch? Before you can bill—and get paid – for chronic care management services, Medicare requires that you have five technical capabilities in place. If that sounds intimidating — it’s not. Several of the five requirements are intertwined, making them easier to complete.
So don’t let technology-induced fear prevent you from receiving the reimbursement you’re due. Before you start billing for time-consuming chronic care management services, make sure you meet the following requirements:
1. For Chronic Care Management, Check That EMR Is CEHRT
CMS requires that you utilize an EHR that’s considered to be “Certified Technology.” This means you must use a system that satisfies the EHR Incentive Programs certification criteria for the recording of demographics, problems, medications, and medication allergies.
As of 2019, you must use 2015 edition CEHRT. These criteria are established by CMS and the Office of the National Coordinator for Health Information Technology (ONC). To find out if your EHR is 2015 editions CEHRT, go to https://chpl.healthit.gov/#/search.
2. Develop a Care Plan for Chronic Care Management Patients
You must develop a Care Plan (updated at least annually) based on an assessment of your patient’s needs in the following areas:
- Physical
- Mental
- Cognitive
- Psychosocial
- Functional
- Environmental
The plan should address all health issues (not just chronic conditions) and should reflect the patient’s choices and values.
A more recent change to chronic care management was enacted in 2020 and states that the CMS Physician Fee Schedule rule defines the care plan elements.
This makes it easier to ensure documentation meets the requirements. Also, you must be able to electronically share the Care Plan. CMS does not specify exact acceptable transmission methods, but it does state that fax transmission is acceptable when the receiving clinician can receive only by fax.
Therefore, you can use email, Internet transfer protocols, etc. provided they are HIPAA-secure (i.e., encrypted email). Important: Although you must have a Care Plan in place to bill for chronic care management, preparing it is not part of CCM reimbursable services.
Instead, you should bill work associated with developing a Care Plan separately with code G0506 (Comprehensive assessment and care planning for patients requiring chronic care management services [billed separately from monthly care management services]). In addition, you can count the extended time to revise an existing care plan toward the requirements for reporting 99487 and +99489.
3. Provide Complete Access for Chronic Care Management Patients
You must provide your chronic care patients with 24/7 access to physicians, other qualified healthcare professionals, or clinical staff. The goal is to provide your patients and their caregivers with the ability to contact healthcare professionals in your practice to address urgent needs regardless of the day or time.
Tip: To provide this level of access to your patients, some experts recommend establishing a dedicated phone line that connects patients/caregivers with a nurse or other clinician for assessment and guidance. You also can use third parties if your practice does not always have staff available.
Your patient must be able to schedule successive routine appointments with a designated member of your care team.
You also must provide enhanced opportunities for patient/provider communication by telephone and asynchronous consultation methods (e.g., secure messaging), although the patient is not required to use these additional methods — you just need to make them available.
4. Facilitate Transitions of Care – Chronic Care Management Options as of 2020
CMS and CPT guidelines state that chronic care management services include Transitional Care Management (TCM) services (99495-99496). Accordingly, you can’t bill separately for TCM services during the same month as chronic care management (99490, 99487, +99489). Chronic care management includes the following TCM services when performed during the same month:
- follow-up with patients after emergency department visits and provide post-discharge TCM services
- coordinate referrals to other clinicians
- share information digitally with other clinicians
Chronic care management changes enacted in 2020 state that you’re able to bill TCM and chronic care management together, per the 2020 CMS Physician Fee Schedule changes. Look for a note in CPT guidelines to undo this 2019 bundle. “CPT codes 99490 and 99491 should be added to the list of care management codes that can be billed concurrently with TCM when relevant and medically necessary,” stated CMS in 2020.
In the 2021 Medicare Physician Fee Schedule final rule, CMS established code 99439 (Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month) as the permanent CPT code to replace G2058. You can use 99439 up to two times in one calendar month, and if necessary, you can bill with transitional care management codes 99495-99496.
5. Coordinate Care – Chronic Care Management Documentation Eases in 2020
Providers must be able to coordinate with home and community-based clinical service providers — including home health, hospice, outpatient therapies, durable medical equipment, transportation services, nutrition services, etc. — to meet the patient’s psychosocial needs and functional deficits.
The provider must document communications with these services in the patient record. The time that clinicians spend performing this coordination does count toward your 20+ minutes of non-face-to-face patient time to qualify for chronic care management reimbursement when calculating your overall time. In 2020, CMS eased this regulation in by stating that while it’s important to indicate the staff participating in the care, you don’t have to name everyone.
As the number of aging patients you care for continues to increase, the importance of understanding chronic care management will grow. Medicare chronic care management billing is complicated, BUT, if you do it right, you can get paid for the additional care you provide to your chronically ill patients. In our session, Earn $50,946 More a Year for Treating Your Chronically Ill Patients, billing and coding expert, Kim Huey MJ, CHC, CPC, CCS-P, PCS, CPCO, can help. In her 90-minute online training she will give you a step-by-step breakdown of the complexities of how to accurately, and more successfully, bill Medicare chronic care management. Sign up for this training today!
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