FAQs chronic care management medicare reimbursement billing

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FAQs – Chronic Care Management Medicare
Reimbursement Billing
www.healthviewx.com

FAQ Patient Eligibility

According to the Centers for Medicare & Medicaid Services (CMS), CCM is for “patients with two or more
chronic conditions. A chronic condition is expected to last at least 12 months or the patient’s entire lifetime.
The condition should be diagnosed to place the patient at significant risk of death, or functional decline.
Are all Medicare patients eligible for CCM reimbursement?

CMS has not specified or listed the eligible chronic conditions that meet this definition. CMS does have a
databank regarding chronic conditions (http://www.ccwdata.org) that care providers can use. However, this
list is very narrow. In general practice, CMS requires a clear communication within the care plan that the
chronic conditions being treated post a significant risk of death or functional decline.
How can a care provider decide which condition meets CMS’
definition for CCM eligibility?

CMS CPT codes can be used while billing for CCM treatment given to Medicare beneficiaries who
are also eligible for Medicaid.
What about patients who are Medicare beneficiaries but also
eligible for Medicaid?

An initial appointment must be fixed for a comprehensive evaluation of the patient. This is known as a
“Welcome to Medicare” visit and includes an initial preventive physical examination. A patient must have
received an introduction to Medicare CCM billing in person to be able to bill separately for CCM services.
Until the changes made in 2017, a consent form signed by the patient was mandatory during the patient’s
initiation into the CCM program. As per the CMS requirement, the consent form is no longer mandatory.
How to kickstart the process of bringing a patient under CCM care?

FAQ Scope of Services

CMS defines the scope of CCM services in the following way:
1. Provide patients with access to care management services at any time of the day. This means patients
should be able to contact the care provider during any emergency or urgent chronic care need 24-hours-
a-day, 7-days-a-week. This may be through calls, SMS, email, internet applications or other means
agreed upon by the patient and care provider.
2. Established care continuity with a designated provider with whom the patient is able to schedule
appointments, discuss care plan compliance, report vital stats and discuss any discomfort that arises.
What are the scope of services for CCM reimbursement as
defined by CMS?

3. Creation of a patient-centered care plan document taking into consideration the physical, mental,
functional and environmental factors of the patient. This includes an assessment of the support system and
resources accessible to the patient.
4. Care management for chronic conditions including assessment of patient’s medical, functional, and
psychosocial needs. Regular follow-ups to ensure timely receipt of all recommended preventive care
services, adherence to the suggested care plan and timely medication.
5. Regular follow-up after a patient visits the emergency department, after discharges from the hospital or
other healthcare facilities. Coordination with home/community based clinical service providers to support a
patient’s care plan adherence.
defined by CMS?

5. Regular follow-up after a patient visits the emergency department, after discharges from the hospital or
other healthcare facilities. Coordination with home/community based clinical service providers to support a
patient’s care plan adherence.
6. Use of certified electronic health record (EHR) and a patient consent form were mandatory until the
changes in 2017 which made them optional.
defined by CMS?

FAQ Chronic Care Management CPT Billing Codes and
Payment

Which CMS Medicare billing codes can be used to bill CCM?

Yes. After the deductible is met, the 20 percent coinsurance charged to the patient will be about $8 to $9
for a month’s work of CCM with CPT 99490.
Are CCM services subject to Medicare’s co-paying system?

According to CMS, CPT code 99490 can be billed only for CCM services provided to a patient who is
currently not the inpatient of a hospital. The patient must not be residing in a facility that receives payment
from Medicare for that beneficiary.
Can you bill CCM for patients in an assisted living facility?

Physicians and Non-Physicians can claim reimbursement by billing for CCM CPT codes. CCM code is most
likely to be billed by primary care physicians. However, specialists, nurse practitioners, physician assistants,
clinical nurse specialists and certified nurse midwives who meet the requirements may also bill for these
services.
Is billing for CCM services limited to primary care physicians?

Yes , it can.
Can the non-face-to-face time spent creating the care plan count
toward the 20 minutes necessary to bill 99490?

FAQ Care Plan

The plan of care should include details of the following elements:
● Problem list detailing the chronic conditions the patient suffers from
● Expected outcome and the likely course of the disease
● Measurable treatment goals
● Symptom management
● Planned interventions through regular follow-ups and vital data collection from patient
● Medication management depending on any concerns/reactions/improvement reported by the patient
● Care coordination plan between care provider and patient’s caregiver such as family/nurse/community
housing etc
● Requirements for periodic review and revision of the care plan as required.
What does the care plan have to include as required by CMS?

Yes. CMS requires the care provider to share the care plan with the patient in a written or
electronic format.
Do I have to provide the patient with a copy of the care plan?

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FAQs chronic care management medicare reimbursement billing

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