How to Implement Chronic Care Management (CCM) Codes in a Clinical Practice: Part 2

Part one of this series provided an overview of the Remote Physiological Monitoring (RPM) codes. Readers are encouraged to read part one prior to part two.

In part two of the series, we shift from RPM to the Chronic Care Management (CCM) codes.

While RPM codes require the use of an integrated technology component, CCM codes have no such device requirement. They do, however, center around a specific care protocol document called a ‘Comprehensive Care Plan,’ the components of which will be explored in greater detail below.

In general, CCM focuses much more heavily on the communication between patient and provider than RPM. Importantly, a CCM program requires significantly more services to be set up and staffed before any billing may begin, which can be a challenge for smaller practices that lack access to a larger pool of shared labor resources, particularly before the program is able to scale up to self-sufficiency.

While CCM code reimbursement is lower on average for a facility than for a non-facility, all of the CCM codes are eligible for reimbursement at either one. In this writing, any examples will be from the perspective of a non-facility practice.

Note that any practice designated by the Centers for Medicare and Medicaid (CMS) as a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC) must follow a different process for CCM furnishment and reimbursement. This series will not explore this area but detailed information from CMS may be found here.

CMS describes the population eligible for payment of CCM services as:

Medicare fee-for-service and dual-eligible (Medicare and Medicaid) beneficiaries with two or more chronic conditions expected to last at least twelve months or until the death of the patient, when those conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

While that may seem like a relatively high bar, many common chronic conditions are actually eligible. According to the official guidance from CMS, examples of eligible conditions include (but are not limited) to the following:

• Alzheimer’s disease and related dementia
• Arthritis (osteoarthritis and rheumatoid)
• Asthma
• Atrial fibrillation
• Autism spectrum disorders
• Cancer
• Cardiovascular Disease
• Chronic Obstructive Pulmonary Disease
• Depression
• Diabetes
• Hypertension
• Infectious diseases such as HIV/AIDS
• Substance use disorders

Chronic conditions not listed here can still be eligible for CCM, so long as the provider can justify that ongoing management of the conditions can reasonably be expected to improve patient outcomes in a measurable way. Practices are strongly advised to consult with their billing compliance expert for guidance on formalizing a clinic-specific eligibility protocol that is meaningful to the specific patient population.

A practice that does not have a dedicated billing compliance contact is advised to consult with an outside expert for guidance before any further investment is made into building a program.

It is easier for many clinics to initiate RPM programs than CCM, due to the required components that must be put into place prior to launch. These components are as follows:

• Continuity of care, by way of designating a team member for the patient as their ‘assigned provider’ in the team (ability to schedule with ‘nurse pool’ only for successive visits is not acceptable).
• 24/7 access to a member of the care team for acute issues related to the chronic diseases being treated (a delay in returning a call is acceptable; a call center simply taking down the message is not).
• Enhanced communication opportunities with the assigned provider made available not only by phone, but also by an electronic messaging portal or similar asynchronous communication system. Note the specific reference to the assigned provider and not to the care team pool for this requirement.
• Transitional and home or community-based care services coordination, which requires oversight of transitions between and among healthcare providers and settings (e.g., referrals, emergency department visit follow-up, facility discharge) by serving as a central hub for generating and exchanging appropriate care documents and relevant summaries, and transmitting them to other practitioners and providers in a timely manner using an electronic communication or by fax.

Every component above must be put into place and ready for utilization before any CCM services may be billed. There are no exceptions to this requirement. If your practice is unable to provide even one of these services in full, then your practice is not eligible to furnish and bill for CCM services.

Note that time spent on the above activities, if utilized on a given month, do count for the purpose of accruing eligible ‘activity minutes,’ which must accumulate to various amounts as indicated by each CPT code. A patient is not required to use all of them on a given month for the clinic to bill, but the clinic is required to have them readily available, and interaction in some fashion is required for CCM billing to occur each month.

There are companies that offer services for outsourcing some of these components, but the labor burden on the medical providers of the clinic cannot be avoided, so the value-added claims of such external groups should be assessed critically, and contracts should be carefully reviewed by an experienced attorney as well as a billing compliance expert.

After the required service components have been put into place, then patients may begin being enrolled in the CCM program. Like RPM, the CCM journey begins with a face-to-face visit. This visit must take place with the intended billing practitioner, and it must be sufficiently comprehensive. Eligible visit types include:

• E&M visit of levels two through five
• Annual Wellness Visit (AWV)
• Initial Preventative Physical Exam (IPPE)
• The face-to-face visit that takes place as part of Transitional Care Management (TCM) services (CPT 99495 and 99496)

Just like with RPM, CCM requires a consent form on file. The form must spell out program benefits and clinical contact information for the 24/7 care team access. It must state in clear language that participation is voluntary, and there may be out of pocket cost sharing for the patient.

Of great importance, it must include specific patient acknowledgement that only one of their providers may furnish and bill for CCM services at any given time. Surprisingly, unlike the RPM consent form that required an updated signature every twelve months, the CCM consent form remains in effect until specifically revoked by the patient.

After obtaining patient consent, a comprehensive care plan is developed with the patient and memorialized in their electronic medical record. The care plan development activity must be performed by the intended billing practitioner—it may not be performed by clinical staff, and it may not be done over the phone at a later time.

The plan is only valid for a twelve-month period, so it is critical to plan ahead and schedule those critical visits in advance needed to review, revise, and re-execute a new plan every year to avoid losing out on reimbursement revenue while still being obligated to provide the care.

This comprehensive care plan is intended, as described by CMS, to be a:

…person-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed).

The document can be looked at as a detailed road map covering the next twelve months of care for these specific chronic conditions listed, and the justification for their billing. There is no formal template provided by CMS, but they provide guidance by listing the following as elements that would typically be included in a care plan:

• Problem list
• Expected outcome/prognosis
• Measurable treatment goals
• Symptom management
• Planned interventions and accountable individuals for each
• Medication management
• Community or social services ordered
• Description of how the services of any agencies/specialists outside of the practice are to be coordinated
• Schedule for periodic review and, when applicable, revision of the care plan

CMS does not provide an official template beyond the above list of elements, but any clinic is strongly advised to develop their own internal template to standardize the match-up of care plans and resources in consistent manner. This is not only a time-saver for providers, but also helps the billing compliance expert sleep more soundly at night.

The development of this comprehensive care plan may be rather extensive for more complex patients, especially a level two or three visit. If the provider time exceeds that expected for the visit type in developing the care plan, then they are justified in also billing G0506 in addition to the visit code:

HCPCS G0506. “Comprehensive assessment of and care planning by the physician or other qualified healthcare professional for patients requiring chronic care management services.”

G0506 may only be billed by a provider once for a patient, even if the care plan requires significant time reviewing and revising at a later point in time. Only if a different provider takes over the CCM billing may the code be billed again for the same patient at any point (which, of course, would also require the original consent form to be revoked, and a new consent form with the new provider group to be executed).

Recall that in part one of this series that for RPM codes, we covered how there is no restriction on how many providers can bill RPM codes for the same patient at the same time—only that each provider is limited to one device per patient for billing.

In stark contrast, CCM is substantially more limited: only one provider for a patient may furnish and bill for CCM at any given time. The patient (or caretaker) is indeed the responsible party for ensuring they have not enrolled in a second CCM program before formally revoking the consent form of the first.

To complicate matters even further, revoking the consent form—from a billing perspective—does not formalize until the end of the month. The following is an all too common example that any CCM program will frequently encounter, particularly with an older patient population:

Mr. Good receives CCM services from his general practitioner, Dr. Apple. He signed the consent form with Dr. Apple on January 3 of this year, to initiate furnishing and billing for CCM services from Dr. Apple’s clinic. Mr. Good is getting older, and his girlfriend urged him to see a geriatrician, so she scheduled an appointment for him with a new provider in town, Dr. Fogie, on June 14.

At that appointment, Mr. Good finds he really likes Dr. Fogie, and is delighted to hear about the CCM program the clinic offers. Dr. Fogie asks Mr. Good if he already receives CCM from another doctor—as this is required to be part of the consent process. Mr. Good forgets about his current enrollment in Dr. Apple’s program and signs a second consent with Dr. Fogie to initiate CCM.

At the end of the month, both Drs. Apple and Fogie submit their respective CCM charges for Mr. Good’s care. Both practices have active consent forms on file signed by Mr. Good. But only one of the practices will be paid. So what happens?

Generally, the first provider to submit the charges that month will receive payment; the second to submit will receive a denial of payment with a letter that states ineligibility due to the other clinic. Practically speaking, this is resolved by the two clinics communication with each other, and then contacting the patient, to explain that they have consented to two CCM programs and may only be in one.

The patient must confirm to both clinics where they wish to continue receiving CCM services, and where they wish to revoke consent. The following month, billing proceeds by only the clinic that maintains active consent per the patient’s directive.

However, for this accidental double billing month, the rights to reimbursement are not based on the patient preference for moving forward. Legally, the practice that holds the consent form with the earlier date of enrollment has the rights to the payment for this month, even if that is the group from which the patient has chosen to discontinue CCM and formally revoked consent. This is because revocation of consent is not formalized from a billing perspective until the very end of the month.

Occasional competing charge submissions will not trigger an audit for a practice unless they continue to occur at a high frequency, which would suggest systemic deficiencies in the consent process that need to be addressed.

CCM codes have the same benefit of RPM codes in that most the codes allow most of the hands-on work to be performed by clinical staff under the provider’s supervision. Naturally (and just like with RPM) the billing practitioner should always be reviewing all activities and notes prior to signing off for any charge to be submitted for payment.

Part one of this series went into greater detail on best practices for tracking eligible activity minutes, and those same practices should be applied for CCM programs as well. Similarly, software programs designed to help minimize errors and optimize revenue per activity minute detail entered may be worth their cost, particularly given that CCM reimbursement is on average greater than that of RPM activity.

At this point, the clinic has already set up the required service components and received the blessing of their billing compliance expert, and the patient has already had their face-to-face visit in which the consent form was signed, and the comprehensive care plan was drafted and memorialized in the chart.

Just as was the case with RPM initiation, tracking of activity minutes to accrue for billing specific codes begins the day following. The patient was determined to fall into the ‘simple’ category during the care plan development, and this was noted in their care plan. It is helpful to think of the simple codes as having two pathways:

• The heavy use of physician time pathway
• The heavy use of clinical staff pathway

It is not permitted to mix and match for the base code and the add-on code, and optimizing reimbursement can be tricky without setting up appropriate automation, even if just a simple excel sheet that calculates eligibility for code bundles and compares the reimbursement rates side by side if more than one bundle is eligible for submission.

CPT 99490. “Chronic care management services, initial 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements: 1) Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; 2) Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 3) Comprehensive care plan established, implemented, revised, or monitored.”

This code allows clinical staff to accrue activity minutes to be counted toward the 20 minutes required for payment. Although not included in the formal code description, CMS has clarified that this code assumes 15 minutes of work by the billing practitioner per month, and that these 15 minutes do count toward the 20 minute total required to bill. In fact, all 20 minutes of time may be performed by the provider directly.

Given that this code is the only one that does not specify the provider time requirement in the description (but rather only the CMS comment does0, many have questioned how carefully the 15 minutes of provider time must be tracked to bill for it. This is a question for your billing compliance expert.

CPT 99439. “Chronic care management services, additional 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements: 1) Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; 2) Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 3) Comprehensive care plan established, implemented, revised, or monitored.”

This is simply the add-on code to 99490, for each additional 20 minutes of clinical staff time. This does not require an additional 15 minutes of the billing practitioner’s time directly, and up to two of these may be submitted each month along with 99490.

If extensive clinical staff time went into managing the simple patient on this month, but billing practitioner time was less so, this may result in overall higher reimbursement.

CPT 99491. “Chronic care management services, provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified healthcare professional time, per calendar month, with the following required elements: 1) Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; 2) Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 3) Comprehensive care plan established, implemented, revised, or monitored.”

The 99491 base code and its specific add-on code can be thought of as an alternative pathway for the simple patient whose care required the billing practitioner themselves to have more direct involvement on that particular month.

This is not switching the patient to the complex care pathway (which requires formal revision of the comprehensive care plan), but rather, it is intended to provide some flexibility within simple care management as patient needs may shift from month to month and allows the practice to be compensated for use of this higher cost time accordingly while ensuring patient care needs are met.

CPT 99437. ““Chronic care management services, provided personally by a physician or other qualified healthcare professional, each additional 30 minutes of physician or other qualified healthcare professional time, per calendar month, with the following required elements: 1) Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; 2) Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; 3) Comprehensive care plan established, implemented, revised, or monitored.”

This is the add-on code to 99491 for each additional 30 activity minutes performed by the billing practitioner directly. Consider that if an hour of physician time is being spent on the patient, an E&M visit of level four or five, which also would use approximately the same hour of practitioner time, may offer higher reimbursement.

Complex CCM uses different codes that pay on average a higher reimbursement. If the patient’s overall care requires the inclusion of medical decision-making that is moderate to high complexity by the billing practitioner, and the care plan will require at least an hour of clinical staff time each month, then this qualifies them for the complex care management codes instead of simple.

Now, a patient who was simple CCM last month may encounter a change in their conditions that justifies the switch to complex CCM the following month. Similarly, a formerly complex CCM patient may stabilize and become more appropriate for simple CCM billing at some point. But in both scenarios, the care plan document must be substantially revised to reflect the changes needed, so this is not something that should fluctuate back and forth from one month to the next for any patient.

Remember: care management is intended to reduce care costs by planning ahead, by way of the comprehensive care plan that has specific activities and timepoints for completing them.

CPT 99487. “Complex chronic care management services, with the following required elements: 1) Multiple (two or more) chronic conditions expected to last at least twelve months, or until the death of the patient; 2) Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; 3) Establishment or substantial revision of a comprehensive care plan; 4) Moderate or high complexity medical decision making; 5) 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.”

This is the base code for the complex care management services. The activity minutes of clinical staff can count toward the 60-minute total required to bill for the code. Although it is not specified in the code, it is prudent to consider the 15 minute practitioner time assumption at minimum.

CPT 99489. “Each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (List separately in addition to code for primary procedure).”

This is an add-on code for 99487, to cover an additional 30 minutes of time after 99487 requirements have been met. This does not necessitate further practitioner hands on activity, but this may change in the future as codes continue to be revised.

How much revenue can a clinic expect to generate in one year for one chronic care management patient?

For a moderately simple patient, who stayed within simple care management, had a couple months in which more physician time was needed so the 99491 code series was used instead, and occasionally required add-on time blocks to be billed, the estimated year one revenue might look as follows:

Note these are national payment amounts; payment will differ by specific MAC locality and should be looked up in the CMS fee schedule available here.

Now, let’s go to the other end of the spectrum, for a complex care management patient who required intermittent additional time blocks:

Here we can see the revenue has nearly doubled for our one patient, but so has the time needed for managing them per code guidelines. It becomes clear that there is a wide range of scenarios that one may expect in a patient population, and strategic use of clinician and clinical staff resources can make the difference between profit and loss.

Bear in mind that the overhead costs of the required service components that must be put into place before a CCM program can begin are not insignificant, and are not included in this analysis, nor are the variable labor costs of practitioner and clinical staff time required to perform the activities in these tables.

Part three of this series will conclude with commentary on concurrent billing, an exploration on the overhead costs, and how one can estimate them for their own practice to generate a basic profit and loss statement. This is a critical first step in the decision of whether any practice should develop and implement a CCM or RPM type program for their patients.