Yes, You Can Bill For Telephone Calls If…
December 15th, 2015
It’s a head scratcher to me!
For months I’ve been telling providers about CPT Code 99490: Chronic care management services (CCM), at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month…
According to CMS in MLN Matters # SE1516:
“CPT 99490 describes activities that are not typically or ordinarily furnished face-to-face, such as telephone communication, review of medical records and test results, and consultation and exchange of health information with other providers.”
Or the very things providers have been asking how to get reimbursed for years! The national non-facility Medicare allowed for this code is a whopping $43.12…for 20 minutes of clinical staff time!
Yet few of the providers KLA works with are using the code.
When I ask, “why not?,” providers indicate that the record keeping requirements are just too great to justify the $43.12 they will be paid for 20 minutes of their staff time.
If my math is right, that is an hourly rate of $129.36 for staff services? Yes, there may be some initial paper work, but the reimbursement seems well worth the time. Most of the time, the services are ALREADY being rendered. It’s just the documentation that isn’t being done.
The requirements to qualify for payment under 99490 according to CPT are:
- During a month, at least twenty minutes of clinical staff time must be used to address the medical and/or psychosocial needs of the patient; (Clinical staff is defined in CPT and is a person who works under the general supervision of a the billing provider and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service; but who does not individually report that professional service. Clinical staff are medical assistants, licensed practical nurse, etc.)
- The patient must have at least two chronic conditions that are expected to last at least 12 months, or until the death of the patient;
- These chronic conditions must place the patient at significant risk of death, acute exacerbation/decompensation of functional decline; and
- The services must be rendered under a comprehensive electronic care plan established, implemented, revised, or monitored (which of course must be documented in the patient’s chart which can be accessed 24/7.
In addition, CMS requires:
- CCM services must be discussed with the patient during a comprehensive E/M visit, an annual wellness visit or an initial preventive physical exam;
- The patient must consent to receive CCM services. The consent form does not have to be signed at the time of the comprehensive service; and does not have to be signed each month;
- The patient must have telephone access 24/7. This can be provided by an appropriate contracted outside service. Most providers already provide this with an on call service;
- There are also some additional documentation requirements that are detailed at in the MLN Chronic Care Management Fact sheet found at:
If your staff is just too busy to provide the service and appropriately document, MLN Matters also states you can contract with appropriate outside clinical staff to do the work:
A billing physician (or other appropriate practitioner) may arrange to have CCM services provided by clinical staff external to the practice (for example, in a case management company) if all of the “incident to” and other rules for billing CCM to the PFS are met. Because there is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9), CCM services cannot be billed if they are provided to patients or by individuals located outside of the United States.
Because care management is an integral part of the services, Medicare does not allow CCM to be billed during the same service period as home health care supervision (HCPCS G0181), hospice care supervision (HCPCS G0182) or certain ESRD services (CPT 90951-90970). In some cases you CAN also bill transition care management (CPT 99495 and 99496) during the same month. The TM service must be completed before you start the CCM service.
If a provider is a member of an accountable care organization, chronic care management services may be provided by the ACO and thus cannot be billed by the provider. Check with your ACO to be sure.
Practice management guru Don Self estimates a solo practitioner could increase the bottom line by about $5,000 a month by implementing Chronic Care Management Services. A free webinar on CCM available at the top of his page at:
If you are not aware of a reputable CCM service in your area that can assist, Don also has recommendations on CCM services that can help you offer this valuable service to your patients.
In today’s climate of deteriorating reimbursements, CCM can help reverse the trend.
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