Physician Practice

Time is of the essence for reporting complex chronic care management

Physician Practice Insider, January 10, 2017

Patients eligible for chronic care management services (CPT code 99490) are generally chronically ill and have continuous and/or ongoing episodic, chronic medical diagnoses. The majority of these patients are receiving these services within an assisted living facility, while some still reside at home, and others are in a full-service nursing care center.

Complex chronic care management is not reported by location, but provided in coordination with other care providers and, at times, performed by clinical staff that is not necessarily an MD or DO. It is not uncommon to see the clinical staff document, develop, implement, and revise care plans for these complex, chronically ill patients. However, this takes place under the direction of the physician and/or other qualified health care professionals such as a physician assistant or nurse practitioner.

In the 2017 CPT Manual, we have code 99487 with add-on code 99489 for the reporting of complex chronic care management codes (note: code 99488 has been deleted). Providers often document the acronym "CCCC," which stands for complex chronic care coordination, to report these services. Patients needing complex care coordination often have many providers involved with their care, which can include physical therapy, psychiatric and behavioral services, social and home care services, in addition to ongoing internal medicine, and specialty services for cardiology, orthopedics, neurology, urology, etc.

Think of codes 99487 and 99489 as similar to those codes for critical care services, as they are reporting a time-based service, in addition to other qualifiers that must be met.

These codes have been created to assist physicians in billing for time spent coordinating the many different services and medical specialties needed to effectively provide for these complex patients and their medical condition(s), psychosocial needs, and everyday activities.

When billing for complex chronic care management services, we have very specific CPT guidelines. These guidelines state that complex chronic care management services are provided during a calendar month timeframe and include criteria to be met:

  • Establishment or substantial revision of a comprehensive care plan that includes:
    o    Medical, functional, and/or psychosocial problems requiring medical decision making of moderate or high complexity;
    o    Clinical staff care management services for at least 60 minutes under the direction of the physician
  • Patients are treated with three or more prescription medications and receiving other types of therapeutic interventions such as physical or occupational therapy

These codes may not be reported if the care plan is "unchanged" or requires only a "minimal" change (such as a medication change or an adjustment to a treatment modality is ordered).

In addition, the patients that require complex chronic care management services have multiple illnesses, multiple medication use, and the inability to perform activities of daily living, requirements for a caregiver and/or repeat admissions to an inpatient facility or emergency department.

Normally, patients will have two or more chronic continuous or episodic health conditions that are expected to last at least 12 months or until the death of the patient, and the patient is at risk of death, acute exacerbation/decompensation or functional decline. These patients are truly at risk for mortality/morbidity issues.

This article originally appeared on JustCoding. Read the full, detailed article here.

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