Insights

CCM and TCM Codes: Providers Leave More Than Money on the Table

by Mary Kay Thalken, RN, MBA on Mar 13, 2019

Since taking effect the last few years, the chronic care management (CCM) and transitional care management (TCM) CPT codes have accounted for sources of revenue that too many provider organizations have overlooked. Principally, it’s money left on the table.

The Centers for Medicare & Medicare Services (CMS) created the 99495, 99496 and 99490 reimbursement codes to facilitate greater emphasis on post-discharge care management. For instance, CPT code 99490, established for remote telehealth monitoring, provides an average $43 per patient monthly reimbursement for managing patients with two or more chronic conditions.

Due to the time-intensive nature of implementing the types of medical procedures described by the codes along with tracking and reporting, many providers including those at large practices are ill-prepared to submit the requisite criteria for successful reimbursement. In other cases, some providers remain unaware that the codes exist or continue to lack the technology, staff and other resources to build a reimbursable program.

This article presents a short refresher of each of the three CPT codes, the challenges of executing dedicated payment programs, and the use of shortcuts to implement the codes into billing procedures.

Chronic Care Management Code

As of January 1, 2015, Medicare began reimbursing for CCM services under CPT Code 99490. The rationale behind billing for the code’s scope of services is that patients with multiple chronic conditions can: receive assistance needed to properly adhere to their care plan, manage the risks associated with their conditions, and achieve improved outcomes that otherwise would be difficult to achieve without patient monitoring by a qualified care team.

Providers must meet six criteria specific to CCM to bill using 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 dictate.

To that end, the following main categories of care planning must be taken into account when establishing a CCM program at your practice:

Staffing—Practice health administrators must choose to either delegate the extra care planning duties to staff, leaving less time for them to attend current responsibilities, or hire new staff, a costly alternative. Neither option is ideal. In fact, estimates show an average 174 patients are assigned to a single nurse to reach the break-even point.
Training—Hours dedicated to training add to the financial burden placed on providers seeking to implement a CCM program.
Time Tracking—Due to the strict criteria regarding the amount of time spent with each patient, it is critical to invest in timekeeping software and adhere to proper tracking at all times. Keep detailed records to avoid errors that could lead to denied reimbursement.
Patient Introduction—Take time to explain the service to patients, an introduction that is required to submit the code for reimbursement.
Access to Care, Technology Needs and Additional Overhead—These combined categories can be considered the “price of doing business.” For example, they pertain to investment in secure digital infrastructure, necessary workspaces and more.

Learn how you could implement these  CPT codes in your billing procedures!

Transitional Care Management Services

CPT codes 99495 and 99496 are used to report transitional care management services.

While the codes share processes and best practices with CCM, TCM is different beyond the broad strokes of care management in that:

  • The patient doesn’t necessarily need to be diagnosed with a chronic condition.
  • The patient’s 30-day window of care begins on the date of discharge from an inpatient setting.

Managing a different patient population within a shorter timeframe means that different rules apply. Still, the potential revenue opportunities cannot be ignored. According to the American Academy of Family Physicians (AAFP), reimbursement can range from $112 to $233.99 per patient depending on code and facility, for example, a physician’s office versus the hospital.

CMS requires the following TCM requirements to establish a care management program:

  • The transition necessitates management services, for example, 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.
  • The healthcare professional accepts responsibility for care to eliminate any gaps in care between care settings.
  • The medical facility must demonstrate the patient’s psychosocial or medical issues that necessitate intervention.

Two separate CPT codes are necessary for TCM services in that both reflect two slightly different patient categorizations. Code 99495 refers to the patient who requires “moderate medical decision complexity” (face-to-face visit within 14 days of discharge). Code 99496 is specific to the patient who requires “high medical decision complexity” (face-to-face visit within seven days of discharge).

Additionally, all TCM services must hit three criteria to be deemed successful and qualify for reimbursement. The standards are:

  1. Interaction within two days of discharge, with exceptions for those situations wherein the assigned case manager or medical professional is unable to reach the patient.
  2. Non face-to-face services, such as review of tests and procedures, provision of educational materials, and assistance with appointment scheduling and community resources assignment.
  3. A face-to-face visit that must occur within either 14 days (moderate complexity cases) or seven days (high complexity cases).

In reality, the challenges encountered implementing both CCM programs and TCM services are similar. For some provider organizations, establishing these programs is cost prohibitive and labor intensive. The result is not merely missed revenue, but rather the opportunity to dramatically improve care outcomes, enhance quality of life and keep patients out of the hospital for longer stretches of time.

Solution: Outside Counsel

There is a solution. The most effective way to create a CCM or TCM program without overburdening your staff is to enlist the help of an organization that has the coding-related resources in place.

Outsourced entities can work as an extension of your staff to build an effective program that enables successful revenue billing of the three CPT codes 99495, 99496 and 99490, and offers benefits for patients. These programs are led by certified medical personnel who provide the right technology support to scale CCM or TCM services to your practice’s preferences.

The benefits of employing outside expert assistance to implement a CCM or TCM program or both include:

  • Clinical experience—Clinical staff, including CNAs, LPs and RNs, are at the forefront of care management services. Healthcare entities benefit from communication with subcontracted licensed clinicians, and patients can interact with caregivers who understand their needs.
  • Quality time—For CCM, 20 minutes per month is the time required to qualify for reimbursement. Hiring an external resource dedicated to tracking this time with each patient ensures record keeping is updated and patients receive the attention they need—even if a patient warrants more attention than the requisite 20 minutes per month.
  • Interaction—To meet the non-face-to-face services threshold of TCM services, the care team will reach out within the allotted timeframe to connect the patient with educational materials, community resources and other check-ins intended to improve well-being.
  • Live and in person—Because TCM services include an in-person component, the patient will participate in a face-to-face visit with a physician or care team leader scheduled at a time most convenient for both staff and the patient.
  • Seamlessness—Because each patient is paired with a dedicated case manager or care team, that individual never feels “passed off” to a different care provider. Each patient’s chronic care and transitional management services will be a seamless extension of your practice’s services.
  • Your approval—No action is taken without consent from the patient’s physician and care team. All information and specific concerns about the patient are relayed immediately including whether a need for intervention arises.
  • Billing—The hurdles are high in properly processing the necessary billing procedures. Team members must help the provider set up a billing system and ensure accessibility of all patient records in securing consistent approval of services.

CPT codes—99490, 99495 and 99496—represent a low-risk, high-reward revenue opportunity for physicians at practices or clinics of any size. For those wanting to make the most of chronic care management and transitional care management, the codes provide an opportunity to profoundly impact the enhancement of care delivery across the patient’s health journey.

Original article
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Meet the Author

Thalken brings more than 30 years of experience in health-care leadership to our company. Prior to joining the company, she served as Enterprise Vice President for Care Logistics in Atlanta, Ga. She has held executive leadership positions at hospitals in Nebraska and Iowa, including the position of System Quality Executive for Alegent Health. Thalken has presented on the topics of improving quality, patient flow and throughput at various industry conferences and webinars. Thalken holds an MBA from the University of Nebraska at Omaha. She is a member of the American College of Healthcare Executives, American Organization of Nurse Executives and American Case Management Association.

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