umm-ccm-billing

Medicare’s Chronic Care Management (CCM) program reimburses doctors for at least 20 minutes of “non-face-to-face” care–in other words, communication via telephone, computer, or mobile device. The goal is to reduce the cost of care for people with multiple chronic conditions with more frequent and more convenient check-ins to monitor the patient’s condition and catch small issues before they become large issues.

The billing code for CCM, CPT code 99490 is, as might be expected, confusing in some areas. CMS has published some billing guidelines to clear up some of the most frequently asked questions.

  1. What qualifies as clinical staff? CPT code 99490 allows “clinical staff” under the doctor’s supervision to deliver CCM care. There have been some questions about what qualifies as clinical staff. CMS defines clinical staff as the physician or “physician assistant, nurse practitioner, clinical nurse specialist or certified nurse midwife.” CMS “incident to” billing rules are still in effect, and staff must comply with supervision, applicable State law, licensure and scope of practice requirements. CMS adds, “other staff may help facilitate CCM services, but only time spent by clinical staff may be counted towards the 20-minute minimum time.”
  2. Can CMS services be outsourced to a third party provider? CMS says, “A billing physician (or other appropriate practitioner) may arrange to have CCM services provided by clinical staff external to the practice (for example, a case management company) if all of the “incident to” and other rules for billing CCM to the PFS are met.” However, CCM services may not be reimbursed if performed by providers outside of the United States.
  3. Does a practice need to perform all CMS services in every billing period? All services should be provided, CMS says, unless they are deemed medically unnecessary or don’t apply to the patient. For example, “if the beneficiary has no hospital admissions that month so there is no management of a transition after hospital discharge.”
  4. When should a practice bill CMS? The billing term for CCM services is one calendar month. Practices may bill CMS at the end of the calendar month or as soon as 20 minutes of care have been delivered to a specific patient.
  5. Can CCM services deliver in outpatient or hospital-owned facilities that are not provider-based? Yes, “If the patient resides in a community setting and the CCM service is provided by or ‘incident to’ services of the billing physician (or other appropriate billing practitioner) working in or employed by a hospital, CPT 99490 can be billed to the PFS and payment is made at the facility rate (if all other billing requirements are met).”
  6. Can a practice bill CMS for CCM service delivered in nursing facilities or assisted living facilities? Yes, when conditions are met. “If all the CCM billing requirements are met and the facility is not receiving payment for care management services (for example, the beneficiary is not in a Medicare Part A covered stay), practitioners may bill CPT 99490 for CCM services furnished to beneficiaries in skilled nursing facilities, nursing facilities, or assisted living facilities.
  7. Is a new consent form required each billing period or each year? No. A new consent for is only required if a patient changes billing providers.

For more CCM billing FAQs visit the CMS website.

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