Some professions are impossible to contain inside working hours. Teachers work more hours than the school day or school year would suggest, for instance. And we know well that physicians also work far more hours than is revealed by hours billed or patients seen. One of the common refrains we hear from clients who rely heavily on physician practices or physician procedures for their revenue is that physicians spend a great deal of time on patient care activities that can’t be billed because they aren’t direct interactions with patients. For example, if a physician spends an hour every few weeks calling a patient’s cardiologist to ensure they are coordinating care, many practices believe that’s an hour of time that can’t be billed.
Now, however, they could bill for it. And so can your organization. As part of an effort to encourage more emphasis on patient outcomes, the Centers for Medicare and Medicaid Services last year began allowing Medicare payments under the Medicare Physician Fee Schedule (PFS) for the American Medical Association’s Current Procedural Terminology (CPT) code 99490, which covers face-to-face care coordination services for Medicare beneficiaries with multiple chronic conditions.
What Is CPT Code 99490 and How Does It Change Chronic Care Coding?
CPT code 99490 allows a provider to collect $42.60 once per month for each eligible patient for activities related to chronic care management (CCM). The development of the code continues the trend of Medicare beginning to reimburse for non-face-to-face care, following the 2013 authorization of transitional care management codes. Overall, payers, in general, are more focused on patient outcomes than ever.1
The payout for using CPT code 99490 might not cause any revolutionary changes in your revenue cycle, but if your organization cares for a high number of patients with multiple chronic conditions (we see this relatively often with providers who see considerable senior populations), then being able to bill for even 20 minutes of staff time per month per patient can offset some previously uncompensated costs. Consider that if you have even just 100 patients who qualify, you could see revenue jump of more than $50,000.
You may bill for the CPT code 99490 for a patient if:
- They have at least two or more chronic conditions, which are defined as conditions expected to last 12 months or until death. The conditions must place the patient at significant risk of functional decline, acute decompensation or death.
- Your organization provides the patient 20 minutes or more of non-face-to-face chronic care coordination, such as consulting with other providers about a patient care plan or managing care transitions between healthcare settings.
- You have created a patient-centered care plan and also provided the patient with a copy, written or electronic.
- The beneficiary has been educated about and paid an additional copay.2
Providers should consider the cost-benefit analysis of billing for CPT code 99490, however. It is not, ultimately, an easy code to bill. Some providers may find that it requires an overhaul of significant portions of their billing workflow, though if you work with a professional revenue cycle partner who handles billing, they should certainly be prepared to make these adjustments to help you bill for 99490 should you desire to do so. 3
Using CPT Code 99490 Properly Will Benefit Your Revenue Cycle
Implementing a billing workflow for CPT code 99490 need not be a taxing or intensive process, nor does it mean completely overhauling your systems. Particularly if you’re already engaged in good revenue cycle management techniques, implementation can be relatively painless.
To begin billing for CPT code 99490, you should:
- Be using an EHR system. If you’re not already using an EHR or are on an older system, you will not be able to bill for 99490. EHRs must meet specific requirements for to bill for 99490. You should consider transitioning your EHR if you haven’t already because an updated system will bring you more benefits than just being able to bill for this code.
- Ensure that your EHR system can handle the requirements. For instance, it will need some way to create patient bills with the 99490 code during each 30-day period, and not exceed a 30-day billing period per patient.
- Educate clinical staff on how to record time for CCM data. Since it does not involve face-to-face care, staff may need to be instructed on how to track time spent on these activities. This could be another area where your current EHR system may fall short. If it does not allow you to log time toward specific activities, you will not be sure if your staff is reaching the 20-minute/month threshold per patient to be eligible to bill 99490.
- Ensure that only one provider bills the CCM code for each patient, each month. This can require some additional coordination with other providers because many patient care plans will include multiple physicians and specialists, especially if your organization is a specialty practice.4
We’ve heard from some clients that concerns over the time and effort required to coordinate with other providers and create care plans are preventing them from even bothering to bill for this code. We certainly understand that decision, but at the very least, any organization who might benefit from billing for chronic care coordination should take a look at its data and evaluate whether it might be worthwhile to run some models on potential reimbursements vs. time to gather enough information to make each claim. Ideally, the practice should identify the population and assign a person (such as a midlevel provider) to manage the population as they would for any other quality measure.
The overall trend toward value-based care is not going away. Even if your organization is not currently prepared or convinced by your cost-benefit analysis of CPT code 99490 to make the move toward implementing systems to gather data for non-face-to-face interactions, or to move toward EHR systems that would allow for participation in value-based billing, you should consider engaging in some future planning.5
Ultimately, optimized revenue cycles will require more precision from all of us to combat shrinking margins and the ramifications of increased patient payer responsibility. In that light, it’s a good idea for CFOs and other provider executives to keep in mind that they should prepare for a future in which billing is much more centered around patient outcomes rather than specific, discrete patient interactions. Even as we work with our clients on the day-to-day reality of managing their revenue cycles now, we always have our eye on forecasting the future of lifecycle management.
Physician Revenue Navigators is a leading healthcare revenue cycle management partner, supporting healthcare organizations of all different practice types in all aspects of a healthy revenue lifecycle, including coding, billing, contractual adjustments, collections, HIPAA compliance and more. Contact us to learn more about how we can assist your organization.
- “Chronic Care Management Services,” May 2015, Centers for Medicare and Medicaid Services, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. ↩
- Seth Flam, “Chronic Care Management: How Physicians Can Increase Practice Revenue without Seeing More Patients,” Electronic Health Reporter, December 19, 2014, http://electronichealthreporter.com/chronic-care-management-how-physicians-can-increase-practice-revenue-without-seeing-more-patients/ ↩
- Travis Bond, “The Secret Code to Unlocking the Benefits of CPT 99490,” Healthcare IT News, November 16, 2015, http://www.healthcareitnews.com/blog/secret-code-unlocking-benefits-cpt-99490 ↩
- Jeffrey Bendix, “Getting Paid for Chronic Care,” Medical Economics, December 18, 2014, http://medicaleconomics.modernmedicine.com/medical-economics/news/getting-paid-chronic-care?page=0,0. ↩
- Elaine Pofeldt, “Physician Payment Outlook for 2015,” Medical Economics, January 9, 2015, http://medicaleconomics.modernmedicine.com/medical-economics/news/physician-payment-outlook-2015?page=full. ↩