Providing and Billing Medicare for Chronic Care Management
Published on Dec 04, 2015
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Providing and Billing
Medicare for Chronic Care Management
The financial and human cost of chronic disease – like cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions, and mental illness – is staggering!
Today, 133 million Americans – one-third of the total population – suffer from at least one chronic disease.
70% of all deaths result from chronic diseases.
85% of all healthcare dollars go to treatment of chronic diseases.
Photo by Philip Taylor PT
Research studies have demonstrated time and again
that care management educes total costs of care for chronic disease patients while improving their overall health.
Despite these impressive results, patients receiving care management services remain the exception, not the rule.
Historically, payers have taken the position that
payment for non-face-to-face care management services is bundled into the
payment for face-to-face evaluation and management (E&M) services.
But these payments do not cover
the significant staffing and technology investments
required for chronic care management, and thus providers do not furnish these services.
As a result, chronic disease patients are too often left
to manage for themselves between episodes of care.
That pattern of sporadic care translates into higher
complication rates which, in turn, means more suffering and costly care.
Since 2011, states can apply for federal funds to pay providers to furnish specified “health home” services
for Medicaid recipients with certain chronic diseases.
These services include comprehensive care coordination
and health promotion.
To date, 14 states have approved programs.
New Medicare Payment for CCM
In the Final Rule, CMS has adopted CPT1 99490 for Medicare CCM services, which is
defined in the CPT Professional Codebook as follows:
We have analyzed those rules carefully, and condensed them down to three core requirements
a provider must meet to bill for CCM:
1. Secure the eligible beneficiary’s written consent.
2. Have five specified capabilites needed to perform CCM.
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