CMS proposes a few clarifications to its chronic care management billing code

By Brian Dolan
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Money TreeAt the beginning of 2015, CMS began reimbursing physicians for the care they provide to a particular group of their Medicare patients remotely and between visits. This new billing code, called Chronic Care Management (CCM), required that this remote care meet a few criteria, like patients must have two or more chronic conditions; the physician must establish a comprehensive care plan for the patient; and the remote care must take up at least 20 minutes of staff time over the course of the month.

This week CMS issued a proposed rule that seeks to clarify the use of the CCM billing code based on the many inquiries the agency has received since the code first came out.

"In reviewing the questions from hospitals on billing of CCM services, we identified several issues that we believe need to be clarified. Therefore, for CY 2016 and subsequent years, we are proposing additional requirements for hospitals to bill and receive OPPS payment for CPT code 99490. These proposed requirements, discussed below, are in addition to those already required..." CMS writes. 

CMS proposes that starting next year CCM can only be billed to if patient has an already established relationship with the provider using the code. "While we have always expected the hospital furnishing the clinical staff portion of CCM services, as described by CPT code 99490, to have an established relationship with the patient and to provide care and treatment to the patient during the course of illness... we have not previously specified through notice-and-comment rulemaking that the hospital must have an established relationship with the patient as a requirement for billing." This prior relationship requirement would be an "explicit condition" on billing to the code, if the proposal is adopted.

CMS also wanted to clarify that while it was previously stated that only one physician can bill to the code for a given patient, the same goes for one hospital for a given patient. "The physician or other appropriate nonphysician practitioner directing the CCM services should inform the beneficiary that only one hospital can furnish and be paid for these services during the
calendar month service period."

For more on CMS' proposed changes and clarifications to CCM and other billing codes, check out the full proposal here (PDF).