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Chronic Care Management: 5 Tips for Billing Success

Health Insurance Companies Process 1 in 5 Claims Wrong

Chronic Care Management - 5 Tips for Business Success

Care Management is not a new concept to health care.

Through the Chronic Care Management (CCM) program, Medicare is taking it up a notch by offering physicians the opportunity to bill for services they are currently managing for free.

With an average reimbursement of $40.82, Medicare’s Chronic Care Management program (billing code 99490) affords practices the opportunity to create a new profit center while improving the experience and clinical outcomes for patients.

Efficient workflows & accurate billing & coding knowledge are key to success with this new revenue stream.

1. What types of practitioners are eligible to bill for the CCM payment?

All types of primary care physicians and specialists, advanced practice nurses, registered nurses, physicians’ assistants, clinical nurse specialists and certified nurse midwives can bill Medicare for CCM. Limited-license practitioners like clinical psychologists and social workers are not eligible as well as non-physician practitioners. Starting January 1, 2016, FQHCs and RHCs became eligible to participate in the program.

2. Can more than one practitioner bill for CCM for the same patient?

No. CMS will only pay for one CCM claim per beneficiary per calendar month. If there are competing claims, CMS will most likely pay the one that is the most recent and has valid written consent from the patient to participate in the program.

Consideration for Practice: 

When just starting out with a CCM program, you might focus on a small number of specific diagnoses, such as diabetes, COPD or CVD.

3. What is my potential revenue if I participate in this program?

There are several factors that determine your revenue but on average, providers can expect to add between $45,000 and $180,000, assuming 100% of your unique patients are covered by traditional reimbursement. Your revenue potential may be less or greater than this estimate depending on the number of eligible patients you have and how many are willing to participate in the program. Want to check your potential revenue?  Here’s a nifty CCM Revenue Calculator    http://www.ehrpmc.com/chronic-care-management-ccm-calculator.html

Consideration for Practice:

An Annals of Internal Medicine practice-modeling study published online in September showed a “typical” practice with about 2,000 Medicare patients could generate more than $75,000 net revenue per full-time physician if half of their eligible patients enrolled in chronic-care management.

They calculated that if a practice hired a registered nurse to work full time on care management, it would need to enroll at least 131 Medicare patients to break even. If they hired a licensed practical nurse, they would need to enroll 76.  (Source: Medicare CCM Payments and Financial Returns to Primary Care Practices: A Modeling Study)

4. When I bill for CCM, are there other services that I cannot bill in that same month?

Yes, there are four services that you will not be able to bill for in the same month as CCM with one exception:

  • Transitional care management (TCM, CPT 99495 and 99496)
  • Home health supervision (HCPCS G0181)
  • Hospice care supervision (HCPCS G0182)
  • Certain end-stage renal disease (ESRD) services (CPT 90951-90970)

The exception to these four situations concerns TCM.

The same practitioner may bill for both TCM and CCM in the same calendar month for the same beneficiary if the 30-day post-discharge service period for TCM concludes before the end of that calendar month AND you have provided at least 20 minutes of CCM services between the time TCM ended and the last day of that month.

Consideration for Practice:

 To find payment information for your specific geographic location, just access the Medicare Physician Fee Schedule Look-Up tool on the CMS website.

5. Which Medicare patients are eligible for Chronic Care Management services?

Medicare patients with two or more chronic diseases that are expected to be present for at least 12 months or until death of the patient. These chronic diseases put the patient at significant risk of death, acute exacerbation or functional decline. CMS hasn’t put out a specific list of chronic diseases because it intends for CCM services to be broadly available. Check out this Chronic Conditions Data Warehouse from CMS!   The warehouse lists about 60 specific chronic conditions that would certainly fit the CCM eligibility profile.

Consideration for Practice:

Practices that approach care with a team effort have an easier time fulfilling the requirements needed to obtain reimbursement for chronic-care management.

Billing extras:

  • CPT code 99490 – The 2015 average reimbursement is $42.60 adjusted based on geography.
  • The practice must have the patient’s written consent in order to bill for CCM services
  • Copayments (coinsurance and deductibles) DO apply.
  • If other E&M or procedural services are provided, those services will be billed as appropriate. That time can NOT be counted toward the 20 minutes. If time, such as from a phone call, leads to an office visit resulting in an E&M charge, that time would be included in the billed office visit, NOT the CCM time.

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What does your practice plan for Chronic Care Management look like?  Leave me a comment below.

is a 20 year veteran of healthcare having managed medical practices. He advises medical practices, physicians and practice administrators on how to run their practice and manage their medical billing and revenue cycle management. Manny speaks, blogs and makes videos at www.CaptureBilling.com, a blog that is tops in the medical billing and coding field. READ MORE

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2 Responses to Chronic Care Management: 5 Tips for Billing Success

  1. What do you think about Urgent Care facilities providing CCM services? We have a great deal of Medicare patients that return to our facility.

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The analysis of any medical billing or coding question is dependent on numerous specific facts -- including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies (as well as coding itself) are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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