While the practice of medicine will always be a professionally and personally rewarding career, it continues to be an increasingly difficult way to earn a living. With rising costs and decreasing insurance reimbursement, current profit margins often rival those of supermarkets (businesses with notoriously low margins). New pay-for-performance models of reimbursement reward practitioners for providing good care and not volume of care but require burdensome and time-consuming documentation in order to receive incentives and not be penalized when receiving payment.
Over the past few years, The Centers for Medicare and Medicaid Services (CMS) has begun reimbursing physicians for services that promote quality and not quantity of care. This article will review some of those new billing codes which do not require the traditional face-to-face encounter that has previously been required by CMS in order to bill for services provided.
Physicians and Non-Physician Providers (NPPs) frequently spend significant amounts of un-reimbursed time reviewing medical records, discussing care with other practitioners, reviewing laboratory studies, etc. Recognizing that coordinating care in this manner will ultimately lead to better patient outcomes, CMS has begun to reimburse practitioners for codes 99358 (prolonged evaluation and management (E/M) service before and after direct patient care, first hour) and 99359 (each additional 30 minutes). This service must be related to a face-to-face E/M code such as a new patient history and physical and it could be performed on the same day as the face-to face service or on another day. The 99358 code is not an add-on code. Code 99359 is an add-on code to code 99358 and must be billed on the same day. This code reflects time spent by the physician or NPP and cannot be used to bill for office staff time spent in similar duties. These codes follow the usual CPT time rules in that more than half of the time specified in the code must be spent in order to bill the code.
Additionally, CMS recognizes that Chronic Care Management (CCM) is a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately for CCM services furnished to Medicare patients with multiple chronic conditions. Chronic care management is care coordination services done outside of the regular office visit for 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. These services are typically non-face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month. Physicians, Physician Assistants, Clinical Nurse Specialists, Nurse Practitioners, and Certified Nurse Midwives can bill for CCM services.
Eight elements define the current scope of CCM services:
1. Access to care management services 24 hours a day, 7 days a week
- Must be able to address urgent chronic care needs regardless of day or time
2. Continuity of care
- Must be able to get successive routine appointments with the same provider of care
3. Care management for chronic conditions
- Systematic assessment of a patient’s medical, functional and psychosocial needs
- System-based approaches to receive recommended preventive care services
- Medication reconciliation
- Oversight of patient self-management of medications
4. Creation of a patient-centered care plan document to ensure that care is provided in a way that is congruent with patient choices and values.
5. Management of care transitions between and among health care providers and settings
6. Coordination with home and community based clinical service providers
7. Enhanced opportunities for a patient and any relevant caregiver to communicate with the provider regarding the beneficiary’s care.
8. Electronic capture and sharing of care plan information.
Before billing CCM services, CMS requires that the provider inform the patient of the availability of CCM services and obtain his or her agreement to have the services provided, document in the medical record the decision to accept or decline the services, inform the patient of the right to stop the services at any time, and inform the patient that only one provider can furnish and be paid for these services during a calendar month. CMS also expects that the discussion will include how CCM services are accessed, how the patient’s information will be shared among other providers in the care time and how the usual Medicare cost sharing (deductible and coinsurance) applies to these services.
Beginning January 2017, the CCM codes are:
- CPT 99490, Chronic Care Management Services, which require at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month and the establishment, implementation, revision and/or monitoring of a comprehensive care plan.
- CPT 99497, Complex Chronic Care Management Services, which require at least 60 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month, establishment or substantial revision of a comprehensive care plan and moderate or high complexity medical decision making.
- CPT 99489, each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. This code is reported in conjunction with code 99487.
It is important to note that CCM services that are not provided personally by the billing practitioner are provided by the clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner) and are subject to applicable State law, licensure and scope of practice. The clinical staff may either be employees or under contract to the billing practitioner whom Medicare directly pays for CCM.
Additionally, CCM codes may not be billed during the same service period of other care management codes such as HCPCS codes G0181/G0182 (home health care supervision/hospice care supervision), CPT codes 90951-90970 (certain End Stage Renal Disease services), CPT codes 99358 and 99359 (discussed above) or CPT 99495 and 99496 (Transitional Care Management Services). The billing practitioner cannot report both complex CCM and non-complex CCM for a given patient for a given calendar month.
The CMS Physician Fee Schedule (PFS) also now includes two Transition Care Management (TCM) codes that allow for reimbursement of the non-face-to-face care provided when patients transition from an acute care setting back to the community. These acute care settings include discharge from an inpatient acute care hospital, an inpatient psychiatric hospital, a long term care hospital, a skilled nursing facility, an inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization at a community mental health center.
During the 30 days beginning on the date the patient is discharged from an inpatient setting, three components of TCM must be furnished:
1. An interactive contact: An interactive contact must be made with the patient and/or caregiver as appropriate, within two business days following the patient’s discharge to the community setting. The contact may be via telephone, email, or face-to-face. It can be made by the provider or clinical staff who have the capacity for prompt interactive communication for addressing patient status and needs beyond scheduling follow-up care.
2. The provider must furnish non face-to-face services to the patient unless it is determined that they are not medically indicated or needed. Clinical staff under the provider’s direction may provide certain non-face-to-face services.
- Services provided by Physicians or NPPs may include:
- Obtain and review discharge information
- Review need for or follow-up on pending diagnostic tests or treatments
- Interact with other health care professionals involved in the patient’s treatment
- Provide education to the patient, family, guardian and/or caregiver
- Establish or re-establish referrals and arrange for needed community resources
- Assist in scheduling required follow-up with community providers and services
- Services provided by clinical staff under the direction of a physician or NPP may include (subject to supervision and applicable state law):
- Communicate with agencies and community services the patient uses
- Provide education to the patient, family, guardian and/or caretaker to support self-management, independent living, and activities of daily living
- Assess and support treatment regimen adherence and medication management
- Identify available community and health resources
- Assist the beneficiary and/or family in accessing needed care and services
3. The provider must furnish a face to face visit as follows:
- CPT code 99495 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision making of at least moderate complexity and a face-to-face visit within 14 days of discharge. The location of the visit is not specified.
- CPT code 99496 covers communication with the patient or care giver within two business days of discharge. This can be done by phone, e-mail or in person. It involves medical decision making of high complexity and a face-to-face visit within seven days of discharge. The location of the visit is not specified.
As can be seen by review of the above mentioned CPT codes as a whole, the common theme is to incentivize medical providers to spend the time to carefully review records, reconcile medications, discuss care with other providers to coordinate care and reduce unnecessary testing, ensure patients receive needed ancillary services, appropriately educate patients about their disease processes and treatment regimens, etc. These items are care and services that have always been provided but probably not given the attention they deserved. Now that CMS recognizes these services as a necessary part of good medical care deserving of reimbursement separate and apart from the traditional face-to-face encounter, it is a win-win situation for both the provider and the patient.
David Siskind, MD, CMD
Chief Medical Officer