Does Medicare cover Chronic Care Management (CCM)?
The good news is that Medicare covers a service called chronic care management (CCM) that’s designed to help you succeed. Learning about this important benefit can keep you healthy and out of the hospital. What is chronic care management?
What is covered by CCM services?
CCM services that must be documented in the electronic health record (EHR). Covered services include, but are not limited to: Management of chronic conditions Management of referrals to other providers Management of prescriptions Ongoing review of patient status Non-complex CCM (CPT code 99490) Requirements:
Who is eligible for chronic care management services?
Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are eligible for CCM services.
When does Medicare require a CCM visit?
INITIATING VISIT For new patients or patients not seen within 1 year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visit with the billing practitioner).
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.
What is CCM for Medicare?
Chronic care management (CCM) services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.
Does Medicare Cover Case managers?
Medicare Part B covers care management for chronic conditions. The goal of care management is to provide you with high-quality, coordinated care to better maintain your health and functioning. You are eligible for Medicare coverage of care management if you have two or more chronic health conditions.
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
Which of the following may bill for CCM service?
Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Nurse Midwives can bill for CCM services.
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.
What is the difference between case management and care management?
Care management is solely focused on the care of the patient and creating a smooth transition between different treatments and stages of care. Case management focuses on rehabilitation and recovery as a whole, bringing all the aspects together to create one successful journey.
What conditions are considered chronic by CMS?
Chronic ConditionsAlcohol AbuseDrug Abuse/ Substance AbuseCancer (Breast, Colorectal, Lung, and Prostate)Ischemic Heart DiseaseChronic Kidney DiseaseOsteoporosisChronic Obstructive Pulmonary DiseaseSchizophrenia and Other Psychotic DisordersDepressionStroke6 more rows•Dec 1, 2021
What does a chronic disease management plan cover?
GP Management plan (GPMP) Then you should write a plan that describes: the patient's healthcare needs, health problems and relevant conditions. management goals and actions for your patient. treatment and services that your patient will need.
Can TCM and CCM be billed in the same month?
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”.
How do I bill for CCM?
CPT 99491 is used to report CCM services provided by a physician or QHP. Care management costs such as software or management oversight can be included on the cost report.
What is complex chronic care coordination?
It is a special program that provides care coordination assistance to people with ongoing health conditions. The case managers will help you manage your conditions so that you can be as healthy and active as possible.
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.
What is CCM in Medicare?
What is Medicare Chronic Care Management (CCM)? Chronic care management (CCM) services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. The Centers for Medicare & Medicaid Services (CMS) ...
Who can bill for CCM?
Only one physician or other qualified health care professional who assumes the care management role for a beneficiary can bill for providing CCM services to that patient in a given calendar month. While services may be provided by a clinical staff person, the service must be billed under one of the following: Physician.
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.
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.
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.
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 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.
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.
Key Takeaways
Find out more information on how community-based organizations can implement and receive reimbursement for chronic care management (CCM) services to help sustain CDSME programs.
General
There are a wide range of services that can be provided under CCM for Medicare beneficiaries with multiple chronic conditions. While the list below is not exhaustive, it provides examples of the types of services that can be provided:
Personnel
There are no specific credentialing requirements for personnel who deliver CCM services, as long as they operate under the general supervision of a qualified physician or non-physician provider (nurse practitioner or physician assistant) provider. However, personnel should be part of the clinical team, not administrative staff.
CCM and Complex CCM
CCM (also referred to as regular or non-complex CCM) covers 20 minutes of clinical staff time per month (CPT code 99490) for ongoing oversight, management, and care planning. In 2017, the CCM benefit was expanded to include complex CCM (CPT code 99487), which covers 60 minutes of time and allows for moderate to high complexity decision making.
Documentation and Billing
Advance consent for CCM services may be verbal or written. If the consent was verbal, there should be documentation in the electronic health record reflecting this.
CCM and DSMT
CCM services can be offered in conjunction with other Medicare Part B benefits, such as Diabetes Self-Management Training (DSMT). For example, if a beneficiary who is receiving DSMT needs assistance with transportation or has concerns about managing co-occurring chronic condition (s), CCM services can be provided to address those unmet needs.
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What is CCM in Medicare?
Chronic Care Management (CCM) reimburses providers for non-face-to-face care coordination services, including communication with other treating health professionals, medication management and plan of care maintenance. CCM improves a Medicare beneficiary's access to primary care with certified electronic health/medical records technology and other coordination of care.
How long does a chronic condition last on Medicare?
Patients must have two or more chronic conditions (expected to last at least 12 months) with significant risk of death, functional decline, exacerbation or decompensation - E.g., hypertension, heart disease, diabetes, high cholesterol, etc. Benefit expected to cover 2/3 of all Medicare beneficiaries that have these 2 or more chronic conditions.
