Medicare Begins Paying for Chronic Care Management

On January 1, 2015, the Medicare program took a significant step towards recognizing that the role of a physician goes well beyond time in the exam room. For the first time, Medicare will begin paying physicians for chronic care management. Medicare has made slow steps towards paying for other kinds of non-face-to-face services in recent years, however those services have been limited to patients in certain settings such as home health. Last year, Medicare began paying physicians for “transitional care management” for patients who were transitioning out of a hospital setting. At the time that CPT created a transitional care management code, it also created a chronic care management code. However, Medicare had concerns with the original version of the code. In response, the CPT editorial created a new version of the code that will be paid starting in 2015.

First, it is important to distinguish between the set of existing codes that remain. Code 99487 and 99489 describe a service referred to as “Complex Chronic Care Management”. The codes are time-based and require at least one hour of chronic care management services by physicians or clinical staff. These codes remain in the CPT book and may be paid by some commercial payers but are not recognized by Medicare.

The new code for 2015 is 99490. Like codes 99487 and 99489, it is time-based. However, an important distinction is that the code only requires 20 minutes of service in a month in order to be reported. In addition, the time-based coding of 99487 and 99489 means that a patient requiring more care management could be billed for that amount. With code 99490, only 20 minutes is being recognized, regardless of how much time is actually spent.

Code 99490 does not require that the patient be seen face-to-face in the month in which the service is billed. Only one physician may submit the care coordination bill in a month. Like most non-procedural services, the documentation requirements are significant. The medical record must reflect that a comprehensive care plan has been established, implemented, and modified as needed. In addition, the activities that make up the 20 minutes of chronic care management must be documented in order to account for the time if the practice were to be audited. The service may only be provided to patients with two or more chronic conditions.

Payment for chronic care management has been a goal of ASH for many years and the organization is pleased that Medicare is finally paying for the service. However, the payment level for this service is paid at a national average of $42. This level of payment may be adequate if the service is truly limited to 20 minutes. But for many patients with blood disease, the care management may require hours of staff and physician time in a month. ASH encourages members to closely review the billing requirements for this service and be certain to meet the documentation standards if they do choose to proceed with using them. ASH will continue to work with Medicare and other payers to recognize the extensive care management associated with patients with significant and unusual chronic disease requiring specialty management.