Archives: CCM Resource Guide

CPT G0511 - Chronic Care Management for FQHCs

Beginning January 1, 2018, FQHCs will be required to bill CPT G0511 for services previously billed as CPT 99490 or 994987. The key features of the new code are the following:

  • Includes monthly Chronic Care Management
  • Includes Complex Chronic Care Management
  • Includes Behavioral Health Integration provided by Primary Care Physicians
  • Can be billed with other services furnished during FQHC visit
  • A 50% reimbursement increase over 99490
  • Bolsters continuity of care

Requirements for eligibility and participation have not changed.

Resources

CMS, “Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Frequently Asked Questions,” November 2017. [Online: 11/30/2017]. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-RHC-FAQs.pdf


CPT 99496 – Transitional Care Management

As of January 1st, 2013, Medicare began to reimburse for CPT 99496 to improve transitions of care for patients. Specifically the CPT definition of 99496 is:

Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least high complexity during the service period
  • Face-to-face visit within 7 calendar days of discharge

There are many specific scope of service requirements (e.g., coordination with home health agencies, community services, family/caretaker education, medication management) for Transitional Care Management relating to care coordination. These scope of service elements can be provided by clinical staff in a non-face-to-face manner. After provision of the non-face-to-face coordination services by clinical staff, a face-to-face visit with the billing provider is still required.

There are two codes used to reimburse for Transitional Care Management, CPT 99495 for moderate complexity patients and CPT 99596 for high complexity patients. A key difference between these codes is days after discharge in which a face-to-face visit is required, 14 days for CPT 99495 and 7 days for CPT 99496.

Note that there are restrictions around billing both Chronic Care Management and Transitional Care Management in the same time period.


CPT 99495 – Transitional Care Management

As of January 1st, 2013, Medicare began to reimburse for CPT 99495 to improve transitions of care for patients. Specifically the CPT definition of 99495 is:

Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge
  • Medical decision making of at least moderate complexity during the service period
  • Face-to-face visit within 14 calendar days of discharge

There are many specific scope of service requirements (e.g., coordination with home health agencies, community services, family/caretaker education, medication management) for Transitional Care Management relating to care coordination. These scope of service elements can be provided by clinical staff in a non-face-to-face manner. After provision of the non-face-to-face coordination services by clinical staff, a face-to-face visit with the billing provider is still required.

There are two codes used to reimburse for Transitional Care Management, CPT 99495 for moderate complexity patients and CPT 99596 for high complexity patients. A key difference between these codes is days after discharge in which a face-to-face visit is required, 14 days for CPT 99495 and 7 days for CPT 99496.

Note that there are restrictions around billing both Chronic Care Management and Transitional Care Management in the same time period.


CPT 99490

CPT 99490, the primary CPT code used for Chronic Care Management, was introduced by Medicare January 1st, 2015 in an effort to coordinate care, improve clinical outcomes, and manage overall healthcare cost for Medicare’s most high risk patients – the chronically ill. Specifically CPT 99490 reimburses for:

Chronic Care Management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored.

Key features of CPT 99490 include that the code:

  • Can be billed “incident-to” the physician’s services and under “general supervision” requirements so that the program can be provided by a third-party care coordination company
  • Reimburses for non-face-to-face time, meaning it supports telephonic or other remote care models
  • Can be paid recurrently per patient per month provided that all the requirements are met in a calendar month
  • Is a billable service for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

CPT G0506 - Chronic Care Management Care Planning

As of 2017, Medicare is reimbursing for provider time spent assessing Chronic Care management patients and developing a care plan. Specifically G0506 reimburses for

Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services (billed separately from monthly care management services

G0506 is meant to account specifically for additional work of the billing provider in:

  • Personally performing a face-to-face assessment
  • Personally performing CCM care planning

Note that this Chronic Care Management care planning could be face-to-face and/or non-face-to-face, but the time spent doing the CCM care planning must not already be reflected in the CCM initiating visit itself or in the time spent during the monthly CCM (i.e., in CPT 99490, CPT 99487, CPT 99489)

The G0506 code is particularly appropriate when the CCM initiating visit is a less complex visit (such as a level 2 or 3 E/M visit). G0506 can be billed along with higher level E&M visits if the practitioner’s effort and time exceeded the usual effort described in the initial visit E&M code. G0506 can also be billed when the initiating E&M visit addresses problems unrelated to Chronic Care Management and the CCM related work is not included in the initial visit code.

G0506 is meant to be billed only once per beneficiary during the initiation of the patient into Chronic Care Management.


CPT 99489 - Complex Chronic Care Management

Complex Chronic Care Management patients often require several hours of care coordination per month. Accordingly, as of 2017, Medicare is reimbursing for additional non-face-to-face time spent by clinical staff on care coordination via CPT 99489. CPT 99489 is an add-on code for CPT 99487 that reimburses for each additional 30 minutes of care coordination services per calendar month (CPT 99497 reimburses for the first 60 minutes).


CPT 99487 - Complex Chronic Care Management

As of 2017, CPT 99487 is reimbursed by Medicare to account for extended care coordination time spent with especially complex patients. This code reimburses for the first 60 minutes of non-face-to-face care coordination by clinical staff. This contrasts with CPT 99490 which was introduced January 1st, 2015 which reimburses for only 20 minutes of care coordination time. CPT 99487 requires the following elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Establishment or substantial revision of a comprehensive care plan
  • Moderate or high complexity medical decision making
  • 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

The two key differentiators between 99487 and 99490 are the additional time (60 minutes for CPT 99487 from 20 minutes for CPT 99490) and the requirement around medical decision making. In addition, a code reimbursing for additional time (CPT 99489) is available for complex CCM patients being billed under CPT 99487.


CCM Transitions of Care

Chronic Care Management patients are unfortunately often high utilizers of the emergency room and frequently hospitalized. Accordingly, a critical component of Chronic Care Management is managing care transitions between and among health care providers and settings, including referrals to other providers, including providing follow-up after an emergency department visit, and after discharges from hospitals, skilled nursing facilities, or other health care facilities. Alternatively these transitions can be managed under a Transitional Care Management program.


CCM Community-Based Service Coordination

Patients with multiple chronic conditions often have needs that extend beyond the four walls of the clinic. Accordingly, Chronic Care Management requires coordination with home and community based clinical service providers required to support the patient’s psychosocial needs and functional deficits.


CCM Continuity of Care

CPT 99490 has many scope of services requirements (e.g., consent forms, face-to-face enrollment, electronic care plan, clinic staff), however some are less well defined. Continuity of care is a loose requirement under which the CCM patient must be able to obtain regular appointments with the Chronic Care Management billing provider. The specific scope of service requirement is that the patient should receive as part of CCM:

Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments