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. The place of service (POS) on the claim should be the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient) as per #5 above.
What is the Medicaid case management rule?
At the same time, the rule ensures that Medicaid case management services include a comprehensive assessment and care plan that would not otherwise be available to beneficiaries.
What is a case management service?
Further, the IFC clarifies that case management services include assessment of an eligible individual; development of a specific care plan; referral to services; and monitoring and follow-up activities.
Does Medicare pay for chronic care management?
If you have supplemental insurance, or have both Medicare and Medicaid, it may help cover the monthly fee. Chronic care management offers additional help managing chronic conditions like arthritis and diabetes.
How do States pay for Medicaid case management consultants?
In some cases, states will pay these consultants a contingency fee based on their performance in maximizing federal Medicaid reimbursement. The IFC proposes certain refinements and clarifications to Medicaid’s case management benefit that are expected to save the program $1.2 billion over the next five years.
What is the billing code for case management?
T1016 - Case Management Review and Billing Concerns Documentation must support appropriate billing for this code.
How much does Medicare reimburse for CCM?
Chronic Care Management (CCM)CPT 99490 Initial 20 minutes, clinical staffCPT 99437 Subsequent 30 minutes, physician or NPPPrincipal Care Management (PCM)CPT 99426 (previously G2065) Initial 30 minutes, clinical staffCPT 99425 Subsequent 30 minutes, physician or NPP1 more row
Does 99490 need a modifier?
Yes, but you will need to use a 25 modifier. Another option is to move the CCM Date of Service (DOS) to the following day for office visits and following discharge for hospital stays.
Does Medicare cover CCM?
CCM is covered under Medicare Part B. This means that Medicare will pay 80 percent of the cost of service. You'll be responsible for a coinsurance payment of 20 percent.
How often can CCM be billed?
This CPT code describes a minimum number of minutes of service (there is no maximum). Therefore, the practitioner may only bill one unit and one line item of CPT 99490 per calendar month.
Can CCM and TCM be billed together?
2) CCM can be billed concurrently with TCM Previously, CCM time couldn't be billed in the same month for a patient that you are already billing TCM time for. This change now allows you to bill for both TCM and CCM in the same month for the same patient when “reasonable and necessary”.
What is the difference between 99490 and 99487?
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.
What is the difference between 99490 and 99491?
Under CPT 99490, clinical staff supervised by a doctor can perform CCM for billing purposes. The new code 99491 compensates doctors and nurse practitioners for their time spent on CCM related care and requires them to provide such care personally.
Can 99490 and 99487 be billed together?
CPT code 99489 is each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualified health care professional (report in conjunction with CPT code 99487; cannot be billed with CPT code 99490)
What is Medicare management?
Medicare care managed care plans are an optional coverage choice for people with Medicare. Managed care plans take the place of your original Medicare coverage. Original Medicare is made up of Part A (hospital insurance) and Part B (medical insurance). Plans are offered by private companies overseen by Medicare.
Which of the following is a requirement to bill for chronic care management?
Those who do must meet the following three criteria: Patient must have two or more chronic conditions. Conditions are expected to last at least 12 months or until death of the patient.
What is considered chronic care management?
Chronic care management includes a comprehensive care plan that lists your health problems and goals, other providers, medications, community services you have and need, and other information about your health. It also explains the care you need and how your care will be coordinated.
How many times can you bill Medicare for E/M?
Under longstanding Medicare guidance, only one E/M service can be billed per day unless the conditions are met for use of modifier -25. Time cannot be counted twice, whether it is face-to-face or non-face-to-face time, and Medicare and CPT specify certain codes that cannot be billed for the same service period as CPT 99490 (see #13, 14 below). Face-to-face time that would otherwise be considered part of the E/M service that was furnished cannot be counted towards CPT 99490. Time spent by clinical staff providing non-face-to-face services within the scope of the CCM service can be counted towards CPT 99490. If both an E/M and the CCM code are billed on the same day, modifier -25 must be reported on the CCM claim.
How long does a CPT 99490 bill take?
The service period for CPT 99490 is one calendar month, and CMS expects the billing practitioner to continue furnishing services during a given month as applicable after the 20 minute time threshold to bill the service is met (see #3 above). However practitioners may bill the PFS at the conclusion of the service period or after completion of at least 20 minutes of qualifying services for the service period. When the 20 minute threshold to bill is met, the practitioner may choose that date as the date of service, and need not hold the claim until the end of the month.
What is provider based outpatient?
provider-based outpatient department of a hospital is part of the hospital and therefore may bill for CCM services furnished to eligible patients, provided that it meets all applicable requirements. A hospital-owned practice that is not provider-based to a hospital is not part of the hospital and, therefore, not eligible to bill for services under the OPPS; but the physician (or other qualifying practitioner) practicing in the hospital-owned practice may bill under the PFS for CCM services furnished to eligible patients, provided all PFS billing requirements are met.
What is CPT 99490?
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. If these activities are occasionally provided by clinical staff face-to-face with the patient but would ordinarily be furnished non-face-to-face, the time may be counted towards the 20 minute minimum to bill CPT 99490. However, see #12 below regarding care coordination services furnished on the same day as an E/M visit.
What is Medicare outpatient?
Per section 20.2 of publication 100-04 of the Medicare Claims Processing Manual, a hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital. Since CPT code 99490 will ordinarily be performed non face-to-face (see # 11 above), the patient will typically not be a registered outpatient when receiving the service. In order to bill for the service, the hospital’s clinical staff must provide at least 20 minutes of CCM services under the direction of the billing physician or practitioner. Because the beneficiary has a direct relationship with the billing physician or practitioner directing the CCM service, we would expect a beneficiary to be informed that the hospital would be performing care management services under their physician or other practitioner’s direction.
What is CCM certified technology?
Hospital furnished the CCM services using a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31st of the calendar year preceding each Medicare PFS payment year (referred to as “CCM certified technology”). The hospital must also meet the requirements to use electronic technology in providing CCM services that are required for payment under the Physician Fee Schedule, such as 24/7 access to the care plan, and electronic sharing of the care plan and clinical summaries other than by fax.
When is CPT 99490 billed?
CPT 99490 can be billed if the beneficiary dies during the service period, as long as at least 20 minutes of qualifying services were furnished during that calendar month and all other billing requirements are met.
What is case management in Medicaid?
At the same time, the rule ensures that Medicaid case management services include a comprehensive assessment and care plan that would not otherwise be available to beneficiaries. Further, the IFC clarifies that case management services include assessment of an eligible individual; development of a specific care plan; referral to services;
What is a target case management service?
o states may “target” case management services to specific classes of individuals, or to individuals who reside in specified areas of the state. • Clarifies when a case manager’s contacts with individuals who are not eligible for Medicaid, or who are not included in the target population, may qualify as Medicaid case management services.
What is an IFC in case management?
The IFC excludes from the definition of case management services, activities that: o are an integral component of another Medicaid service; o include the direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred; o constitute the administration of foster care programs;
How much did TCM cost in 1999?
Across the nation, total spending for TCM services jumped by 76 percent between 1999 and 2003 from $1.7 billion to $3 billion. GAO officials believe that some of this increase can be linked to a growing trend among states to hire consultants to assist in administering their Medicaid programs.
What is the 6052 rule?
The Centers for Medicare & Medicaid Services (CMS) interim final rule with comment period (IFC) implementing section 6052 of the Deficit Reduction Act of 2005 (DRA) clarifies the Medicaid definition of covered case management and targeted case management (TCM) services. The rule includes measures to address concerns about improper billing of non-Medicaid services to the Medicaid program by some states, while also including significant beneficiary protections that ensure comprehensive and coordinated services to meet the needs of beneficiaries.
How long does Medicare cover inpatient hospital?
Inpatient Hospital Coverage Under Medicare. starts when the beneficiary first enters a hospital and ends when there has been a break of at least 60 consecutive days since inpatient hospital or skilled nursing care was provided.
When was Medicare created?
Medicare is health insurance provided by the government. Created in 1966 under Title XVIII of the Social Security Act. Administered by Centers for Medicare & Medicaid Services (CMS) Covers some but not all medical costs. Pays under the Prospective Payment System (PPS) for most care settings. Eligibility for Medicare benefits:
What is Medicare Part C?
Medicare Part C (Medicare Advantage Plan) Option to get coverage for parts A and B and sometimes D, through a private health plan such as an HMO or PPO. Plans contract with the government to administer Medicare benefits to members. Plans are required to provide services covered in Medicare parts A and B except hospice.
What is a PRO reimbursement?
Reimbursement rates correspond to the level of home health provided. Peer Review Organization (PRO)- A federal program established by the Tax Equity and Fiscal Responsibility Act of 1982 that monitors the medical necessity and quality of services provided to Medicare and Medicaid beneficiaries under the prospective payment system.
How many days of inpatient hospital care is required?
inpatient hospital care is normally limited to 90 days during a benefit period. copayment required for days 61-90. If the 90 days are exhausted, can elect to use days from a non-renewable “lifetime reserve” of up to 60 additional days of inpatient hospital care. (copayment required for these days also)
What is a DRG in medical billing?
Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed. Diagnosis-Related Group (DRG)-A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital.
How long is SNF covered by Medicare?
SNF Coverage Under Medicare. only covered if follows w/i 30 days of a hospital stay of 3 days or more and medically necessary. Limited to 100 days per benefit period. copayment required for days 21-100.
How long do you have to report a patient to a team conference?
Reporting participants shall have performed face-to face evaluations or treatments of the patient, independent of any team conference, within the previous 60 days. Reporting participants should record their role in the conference, contributed information, and subsequent treatment recommendations.
What is 99367 for?
Physicians will be able to report 99367 for a medical team conference with an interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more. Physicians are referred to evaluation and management codes for one comparable to 99366.
What is a telephone assessment?
The telephone assessment codes are for "non-face-to-face assessment and management services provided by a qualified health care professional to a patient using the telephone.
What is chronic care management?
Chronic care management offers additional help managing chronic conditions like arthritis and diabetes. This includes a comprehensive care plan that lists your health problems and goals, other providers, medications, community services you have and need, and other information about your health. It also explains the care you need ...
What is deductible in Medicare?
deductible. The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay. and. coinsurance. An amount you may be required to pay as your share of the cost for services after you pay any deductibles.
Does Medicare pay for chronic care?
Chronic care management services. Medicare may pay for a health care provider’s help to manage chronic conditions if you have 2 or more serious chronic conditions that are expected to last at least a year.
Question Billing for Case Management (98966-98968)
Hello. I am new to billing for Behavioral Health and I want to make sure I'm doing so correctly. Any help to lead me in the right direction is appreciated so, thank you in advance! I have a therapist that sent me a message for me to bill "Case Management via Telephone" for a patient. When...
Encountering multiple services for open Medicaid client
I work for a Medicaid managed care organization and am wondering about the appropriateness around encountering/billing multiple services for a client when the client is open to services in multiple facilities. For example, if a client is in a psychiatric residential treatment facility, can a...
H0006 another code
BC is now denying case management code H0006 stating H and T codes are to be billed by Medicaid, any suggestions on a replacement code? Thanks
What is a behavioral health care manager?
As noted in the CY 2017 PFS final rule, (81 FR 80231), the behavioral health care manager is a designated member of the care team with formal education or specialized training in behavioral health (which would include a range of disciplines, for example, social work, nursing, and psychology), but Medicare did not specify a minimum education requirement. They may or may not be a professional who meets all the requirements to independently furnish and report services to Medicare. The behavioral health care manager must be available to provide services face-to-face with the beneficiary, have a continuous relationship with the beneficiary, and have a collaborative, integrated relationship with the rest of the care team. He or she must also be able to engage the beneficiary outside of regular clinic hours as needed.
Who can bill BHI codes?
The BHI codes can be billed (directly reported) by physicians and non-physician practitioners whose scope of practice includes evaluation & management (E/M) services and who have a statutory benefit for independently reporting services to Medicare . This includes physicians of any specialty, physician assistants, nurse practitioners, clinical nurse specialists and certified nurse midwives. Generally, we would not expect psychiatrists to bill the psychiatric CoCM codes, because psychiatric work is defined as a sub-component of the psychiatric CoCM codes. However, General BHI could be billed by a psychiatrist who furnished the services described by the general BHI code and met all requirements to bill it.
What is a referral for BHI?
The BHI services require that there must be a presenting psychiatric or behavioral health condition that, in the clinical judgment of the treating physician or other qualified health professional, warrants “referral” to the behavioral health care manager for further assessment and treatment through provision of psychiatric CoCM services or General
What is the difference between BHI and CCM?
There are substantial differences in the potential number and nature of conditions, types of individuals providing the services, and time spent providing services. CCM involves care planning for all health issues and includes systems to ensure receipt of all recommended preventive services, whereas BHI care planning focuses on individuals with behavioral health issues, systematic care management using validated rating scales (when applicable), and does not focus on preventive services. CCM requires use of certified electronic health information technology, whereas BHI does not. In most cases, we believe it would not be difficult to determine which set of codes (BHI or CCM) more accurately describe the patient and the services provided. As we state in the final rule, the code(s) that most specifically describe the services being furnished should be used. If a BHI service code more specifically describes the service furnished (service time and other relevant aspects of the service being equal), then it is more appropriate to report the BHI code(s) than the CCM code(s).
Can BHI be used in both facility and non-facility settings?
Yes, the BHI codes are priced in both facility and non-facility settings. The POS on the claim should be the location where the billing practitioner would ordinarily provide face-to-face care to the beneficiary.
Can a behavioral health care manager report to Medicare?
Yes. As noted in the CY 2017 PFS Final Rule, (81 FR 80231-80232) if the behavioral health care manager is eligible to independently furnish and report services to Medicare, then that individual could report separate services furnished to a beneficiary receiving BHI services in the same calendar month such as psychiatric evaluation, psychotherapy, and alcohol or substance abuse intervention services. Time spent by the behavioral health care manager on activities for services reported separately could not be included in the time applied to any BHI service code (in other words, time and effort cannot be counted more than once).
Is a behavioral health care manager required to be a billing practitioner?
The psychiatric consultant and behavioral health care manager may, but are not required to be, employees in the same practice as the billing practitioner. As noted in the CY 2017 final rule (81 FR 80235), these other care team members are either employees or working under contract to the billing practitioner whom Medicare directly pays for BHI. However, the behavioral health care manager must be available to provide services on a face-to-face basis (though face-to-face services do not necessarily have to be provided). Under the current CoCM model of care, the psychiatric consultant is commonly (but not required to be) remotely located.
