Ask the Coding Experts: Chronic care management services
Ask the Coding Experts, by Doug Morrow, O.D., Harvey Richman, O.D., and Rebecca Wartman, O.D.
From the October 2015 edition of AOA Focus, pages 48-49.
When selecting and reporting Current Procedural Terminology (CPT) codes, all physicians must ensure that the code reported accurately describes the services performed.
Instructions in the 2015Professional Edition Current Procedural Terminology specifically note, "Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code."
Over the past few years, the CPT Editorial Panel and the Centers for Medicare and Medicaid Services (CMS) have given more consideration to the types of care management services that physicians engage in on a daily basis to coordinate care and ensure their patients take steps to maintain and improve health. Under the current coding system, many of these types of care coordination services have no correlating CPT code. However, in 2015, a new code was implemented to report chronic care management services (CPT 99490). While many may be eager to use this new code and some may be encouraging doctors of optometry to begin billing this service, it is critical to be fully aware of all of the requirements related to CPT 99490.
What does the doctor need to do?
Essentially, the physician must develop, implement or monitor the care plan for the patient and either provide or oversee the management and/or coordination of services for all of the patient's medical conditions, psychosocial needs and activities of daily living.
What patients are eligible?
This code can only be reported for patients who have two or more chronic conditions that are anticipated to last at least 12 months or until the patient dies. These chronic conditions must be so significant that they put the patient at risk of death, acute exacerbation or functional decline.
What practice requirements exist?
There are several conditions that must be met to report these services, including:
- Providing patients with 24/7 access to physicians or other clinical staff to address urgent health needs regardless of time or day of the week.
- Using an electronic health record.
- Using a standard methodology for identifying the patients who receive these care management services. There also must be a standard process for identified patients to begin receiving care management services in a timely manner.
- Having the ability to engage both patients and caregivers and coordinate care with other professionals as needed for each patient.
Where are these services provided?
The place of service for CPT 99490 must be the patient's home, domiciliary, rest home or assisted living facility.
What are the time requirements?
At least 20 minutes of clinical staff time per month must be spent in care management activities to report CPT 99490.
While doctors of optometry play a key role in managing many eye-related chronic diseases, it is critical to ensure that all requirements of this code are met prior to reporting these services. Given the significant requirements related to reporting CPT 99490, it is unlikely that this code is the best code to report for care management services provided by the majority of doctors of optometry. Reporting of CPT 99490 without meeting all of the code requirements could result in lengthy and costly audits.
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Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.