In 2014, new codes were added into the Current Procedural Terminology (CPT) code set to report complex chronic care coordination services, known as C4 services. This code set has been revived for 2015 to create a new category titled ‘Care Management Services’. The Affordable Care Act (ACA), the movement towards patient-centered medical homes and pay for performance resulted in these additional changes. The new category is further broken into two sections – Chronic Care Management Services and Complex Chronic Care Management Services. The changes include one new code for chronic care management services and revisions to two current codes for complex chronic care management services.
Chronic Care Management Services
These types of services are provided when medical and/or psychosocial needs of the patient require establishing, implementing, revising or monitoring the care plan. The new CPT code to report them is:
- 99490: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or qualified health professional, per calendar month with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline
- Comprehensive care plan established, implemented, revised or monitored
Services that last less than 20 minutes during a calendar month are not reported separately. However, the physician or QHP may still report evaluation and management services for specific problems be treated or managed as per the CPT level of care.
Complex Care Management Services
Patients who require complex care management services may be identified by practice-specific or other published algorithms that detect multiple illnesses, multiple medication use, inability to perform activities of daily living, need for a caregiver and/or repeat admissions or emergency department visits. Generally, pediatric patients receive three or more therapeutic interventions (for example, medications, nutritional support). The revised CPT codes for reporting these services are:
- 99487: Complex chronic care management with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
- Establishment of substantial revision of a comprehensive care plan
- Moderate or high complexity medical decision making
- 60 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month
- 99489: Each additional 30 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month (list separately in addition to code for the primary procedure).
Complex chronic care management services of less than 60 minutes of duration in a calendar month are not reported separately. You should report 99489 in conjunction with 99487.
What You Must Consider for Correct Coding
For correct coding, you must consider the appropriate documentation and reporting of care management services. The physician or qualified health professional must document as well as share with the patient and/or caregiver a plan of care which addresses the physical, mental, cognitive, social, functional and environmental assessment. This plan must be comprehensive and address all health issues of the patient. It would typically include:
- Problem list
- Expected outcome and prognosis
- Measurable treatment goals
- Symptom management
- Planned interventions
- Medication management
- Community/social services ordered
- Direction and coordination with agencies and specialists unconnected to the practice
- Identification of the individual responsible for each intervention
- Requirements for periodic review
- Revision of the care plan when applicable
In addition to this, the care management services:
- May be reported only once per calendar month and only by a single physician or other qualified healthcare professional, who appears to be in the care management role with a particular patient for the calendar month.
- Include clinical staff time spent on:
- Face-to-face and non-face-to-face communication with the patient and/or family, caregivers, other professionals and agencies
- Revising, documenting and implementing the care plan
- Teaching self-management
The coders should be well-trained in CPT coding as well. If practices find medical coding and billing cumbersome owing to the rising number of patients and limited resources, they can consider using the services provided by professional billing and coding companies.
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