99490. 99495. 99496.
Those three CPT codes account for sources of reimbursement that too many providers have overlooked since their creation in 2013 (99495, 99496) and 2015 (99490).
The Centers for Medicare and Medicaid Services created these Chronic Care Management (CCM) and Transitional Care Management (TCM) reimbursement codes in order to facilitate greater emphasis on post-discharge care management. On the CCM side alone, managing patients with two or more chronic conditions yields an additional $43 per enrolled patient per month in reimbursement1.
But due to the time-intensive nature of implementing the types of care described by the codes and of tracking and reporting time spent on that care, numerous providers, even those in large practices, simply aren’t equipped to successfully submit for reimbursement according to the requisite criteria. In other cases, providers may not know these codes exist or lack the technology, staffing or resources to otherwise pursue a reimbursable CCM or TCM program.
In this guide, we’ll examine what each of these codes are, explain the challenges of implementing programs dedicated to these codes, and detail a shortcut to implementing these three CPT codes in your billing procedures.
Chronic Care Management Vs. Transitional Care Management
It helps to divide these codes up into two separate categories: CPT Code 99490 pertains to Chronic Care Management, or CCM, whereas 99495 and 99496 pertain to TCM. Let’s begin by looking first at CCM.
The whole idea behind CCM is to ensure that patients suffering from multiple chronic conditions get the assistance they need to properly adhere to their care plan, manage the risks associated with their conditions and achieve better outcomes than would be possible without a qualified team monitoring their care.
There are six chief criteria to CCM that must be met in order to bill using the CPT code 99490:
- Every month, the patient must receive at least 20 minutes of care management from clinical staff.
- That care must be guided by a physician or some other type of healthcare professional qualified to supervise and/or plan care.
- The patient must suffer from at least two chronic conditions.
- Those conditions must last more than a year under expected circumstances.
- Said conditions can become worse or pose a risk of “functional decline” or even fatality if not effectively managed.
- A comprehensive care plan must be in place, monitored, and altered as needs dictate2.
It’s this last bullet point that poses perhaps the greatest hurdle to successful CCM efforts. For many providers, the resources needed to implement a successful CCM plan for patients outweigh the benefit of billing for the 99490 CPT code in the first place.
These are the main categories of care planning3 that must be taken into account when establishing a CCM program at your practice:
- Staffing – Physicians’ offices or clinics must choose to either foist these duties onto existing staff, which leaves less time for their existing responsibilities, or hire new staff members, which can be costly. Neither option is ideal. In fact, H3C estimates that it would take 174 patients assigned to a single nurse to reach the break-even point.
- Training – Hours dedicated to training also add to the financial burden placed upon providers seeking to implement a CCM program.
- Time Tracking – Because there are strict criteria for the amount of time that must be spent with each patient, it’s critical to invest in timekeeping software and adhere to proper tracking at all times. Detailed records must be kept, and any slip-up can lead to denied reimbursement.
- Patient Introduction – Time must be taken to explain the service to patients, an introduction that is required in order to be able to submit the code for reimbursement.
- 6. & 7. Access to Care, Technology Needs, and Additional Overhead: Taken together, these three things can be considered the price of doing business. They pertain to things like investment in secure digital infrastructure, necessary workspaces and more.
As you can see, committing to a successful CCM program is not for the faint of heart, but that doesn’t mean it’s not worth doing. Before we get into potential solutions, let’s now turn our attention to the next category of care: Transitional Care Management (TCM).
While it shares processes and best practices with CCM, TCM is necessarily quite a bit different when you look beyond the broad strokes of care management.
The biggest two differences are that 1) the patient doesn’t necessarily need to be suffering from a chronic condition and 2) the management of their care pertains specifically to the 30-day window following discharge.
As you might expect, because you’re dealing with a completely different patient population and a much shorter timeframe, completely different rules apply. Still, the potential revenue opportunities cannot be ignored. According to the American Academy of Family Physicians, reimbursement can range from $112 to $233.99 per patient depending on code and facility (i.e. physician’s clinic vs. hospital).4
According to CMS, these are the main requirements you must adhere to when establishing a program:
- The transition necessitates management services, e.g. there is an ascertained level of risk due to the nature of the patient’s condition
- Responsibility for patient care rests with the healthcare professional overseeing transitional care services
- There is no gap in care between the patient leaving the inpatient setting and their next level of care
- The medical facility must be able to demonstrate that the patient’s psychosocial or medical issues necessitate intervention5
Why two separate CPT codes? Because there are two slightly different categorizations for patients. Here’s how they shake out:
99495: The patient requires “moderate medical decision complexity”
99496: The patient requires “high medical decision complexity”6
In addition, all TCM services must hit three criteria in order to be deemed successful and thus qualify for reimbursement. These are:
- Interaction within two days of discharge, with exceptions set for those situations wherein the assigned case manager or medical professional is unable to reach the patient
- Non face-to-face services, typically things like review of tests and procedures, provision of educational materials, and assistance with appointment scheduling and community resources assignment.
- A face-to-face visit that must occur within either 14 days (moderate complexity cases) or 7 days (high complexity cases).7
Many of the same challenges ascribed to CCM programs also apply to TCM services. That once again means that, for numerous providers, the cost of establishing these programs is prohibitive. That is disappointing, because not only is this a missed revenue opportunity, but these programs by their very nature have the potential to dramatically improve care outcomes, enhancing patients’ quality of life and keeping them out of the hospital for longer stretches of time.
Thankfully, a potential solution exists.
The best way to initiate a CCM or TCM program without saddling your current staff with too much work or your facility with too much debt is to enlist the help of an organization that already has the resources in place to implement a CCM or TCM program.
There are outside parties that actually work as an extension of your own staff to establish an effective program enabling institutions to achieve revenue on the established CPT codes, and that means patients benefit as well. These programs, led by licensed and certified medical personnel not only have the credentials, but also the technology support to provide and scale CCM or TCM services on your behalf.
Here are a few of the benefits of implementing a CCM and/or TCM program using outside assistance:
- Clinical Experience – Clinical staff, including CNAs, LPs and RNs, are the ones leading the care management services, which means healthcare entities benefit from communication with other healthcare professionals, and patients get to interact with persons who understand their needs.
- Quality Time– For CCM, 20 minutes per month is required in order to qualify for reimbursement, and having an external resource dedicated to tracking this time with each patient ensures record keeping is up to date and patients receive the attention they need, even if a patient needs more attention than the requisite 20 minutes per month.
- Interaction – In order to meet the non-face-to-face services threshold of TCM services, the team will reach out within the allotted time frame to connect the patient with educational materials, community resources and various other check-ins that can improve their wellbeing.
- Live and In Person – Because TCM also has an in-person component, the patient will have their face-to-face visit with their physician or care team leader scheduled at a time most convenient for staff and for the patient.
- Seamlessness – Because each patient gets a dedicated case manager or care team, they’ll never feel like they’re being passed off to a completely different institution. For all intents and purposes, the care and transitional management they receive will be an extension of your own services, and the patient won’t even notice the difference.
- Your Approval – Nothing is done without consent from the patient’s physician and care team, and all information and concerns about the patient will be relayed at once, particularly should the need for an intervention arise.
- Billing – The hurdles of properly going through the necessary billing procedures are high, so the team also helps the provider set up a billing system and keeps all records available to ensure consistent approval of services.
The Future of Managed Care
99490. 99495. 99496.
Those codes represent a valid, low-risk, high-reward revenue opportunity for physicians in clinics of any size as well as a chance for providing even better care for patients. If you have additional questions about how CCM and TCM can be brought online at your practice or clinic, please feel free to reach out.
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