Every day you perform all sorts of activities and work that are not directly reimbursed. Wouldn’t it be nice if you could start to get paid for the work you do? Well, perhaps now you can.
Chronic Care Management (CCM).
Effective January 1, 2015, The Centers for Medicare & Medicaid Services (CMS) ruled that health care providers can now bill for reimbursement (indirectly) for the non-face-to-face visits and work that providers do This ruling allows for compensation for direct patient activities that include making phone calls to patients, helping patients fill out forms, consulting over the phone and taking calls after hours from patients. The everyday followup items that practitioners do everyday directly with their medicare/medicaid patients will now be eligible for reimbursement. For practitioners who practice chronic care management this a monumental breakthrough to get compensation for previously undocumented time spent on their patients.
There are certain requirements that need to be met in order for the time spent to be eligible for reimbursement.
- Practitioners (or their staff) must have at least 20 minutes of patient interaction per calendar month. Time cannot be added up over multiple months to report 99490.
- Patients must be medicare patients.
- The patient must be diagnosed with 2 or more chronic conditions.
- The patient also has to give written consent.
- There is a non-waivable monthly copay that is the patient’s responsibility.
Meeting the basic eligibility requirements is just the first step. After verifying that the patient has met the requirements the practitioner must also work with the patient to create a “patient-centered care plan” in conjunction with the patient’s values and needs. This care plan must be submitted to CMS and a copy given to the patient prior to reporting 99490 the first time. The care plan will then be in effect until otherwise changed by the practitioner.
CMS 99490 dictates that patients must have 24/7 access to care. The scope of CCM services must include, “enhanced opportunities for the beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non face-to-face consultation methods”, according to the CMS. So, 24/7 access doesn’t necessarily mean the practitioner has to be available by phone which allows a great amount of flexibility.
The CMS 99490 is a landmark move that will help practitioners potentially expand their practice and maintain a 360 degree picture of care for their patients. Medicare has been establishing a trend toward compensating practitioners for non-face-to-face care. This is the second landmark decision that will impact how practitioners can care for their patients. It is a promising trend that is sure to provide patients and practitioners alike with a more beneficial care experience.
Are you a member of NPBO™? If so, login to the members area for a detailed reports, directions, templates and more of how to utilize the CCM option in your practice. More at www.NPBusinessOwner.com/join.
What about a mental health practice?
What is the monthly fee that the patient has to pay? Do you have to sped to the patient about their care every month?
Jennifer, it would be the 20% of what your allowable is for the CCM. Look up the CPT code Medicare allowable for your area. If the billing is being done under the NP, then reduce it by 15%. The patient is then responsible for 20% of the allowable to you.
Sorry, did not understand your second question.
Interesting idea, since if have done this all along without reimbursement. Telephone time for some of my Medicare patients is unbelievable! I am going to look into this one! Thanks again Barbara!!!
You are welcome Laurie! Let me know how it goes.
Does it have to be a licensed clinician that does the calls such as an NP, RN, LPN, or can it be an MA (Medical Assistant)?
Thanks for all your help and insight!
The work provided by clinical staff employed by the clinician (or the practice) who is billing for the services, count. Receptionist or admin staff do not count. Hope this helps.
How many patients will actual agree to pay a monthly fee though? They are already on a fixed income.
Sorry I missed your question earlier.
This is a concern and it’s one of the reasons patients will need to consent. One way to approach this is to “sell” them on the benefits of what this program can do for them, especially if it can help them reduce other cost (financial and otherwise). Many will consent, especially if it can save them a visit to see you.
Good info. I’m unable to find the resources you listed, even though I am a member. Please advise on how I can access the reports, templates etc.
You’ll find the webinar under the Business Growth section – here is the direct link (you’ll need to log in) – http://bit.ly/2ghjfGq.
Hi Barbara – can this apply to an NP offering purely health coaching specifically to patients with chronic conditions -( but not direct care management )- through a primary physician office that already provides the direct care and 24/7 “on call” service ? TIA !
Offices can outsource the CCM to a service that provides this. However, it really is intended for the office to get reimbursed for all the things they have been doing for years without getting paid – managing medications, prior authorizations, referrals to other providers and services, etc. So in general, unless you are actually providing this service to and for the office and their patients, I would say no.
Thanks for stopping by and asking Millie!
Hi Barbara great article! My company has been assisting Physicians with their CCM and TCM practices since 2015. Just to clarify -CCM does not include the time used for pre-authorizations, this is an administrative function not a ‘care planning/management’ service for the patient. Additionally, co-pays are not required- it is a flat fee of approximately $38 for the basic 20 minute service. CMS has expanded the CPT codes to include up to 60 minutes of care management time.
That’s correct with the new update. Thanks for the clarification Marisela!
I have been implementing and teaching in this subject for sometime-
It can be lucerative if done correctly
You can not bill CPO certs or transitinal care which all reimburse better.
Many patients or families to complain about co-pay it’s about 7.83- 10.12
There are a few requirements including 24 hour call.
Hi, thank you for your article.
Does a FL state NP need a collaborating physician to provide these services? Can a NP lead a chronic care management program without a MD in the state of FL?
Florida requires collaboration for NP practice. You might check with your BON to clarify if anything can be done without collaboration. However, since these are services you’ll be billing Medicare for, keep in mind that Medicare independently requires some form of collaboration, even in FPA states.
Can an RN with a Medicare number bill for this service?
No. Take a look at this. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf
Thanks for your question Linda.
I am a family nurse practitioner in Texas and I am curious if I can start a CCM practice? Are there consultant groups that can be hired to start up a business in this area of healthcare? I currently own a transportation business for elders and looking to expand.
There is no reason why not. There are plenty of people teaching this and will even do the work for you. Keep your eyes open, I’m announcing a webinar where this will be one of the topics in mid-August.
Can a PCP refer the patient to a NP to manage the CCM with the assistance of a RN? Does PCP have to Bill for the CCM or can the NP who is managing the CCM for the PCP bill for it?
Yes. Generally, the practice/agency doing the CCM is the one who bills.