Chronic Care Management Services

Reimbursement Policy:
Chronic Care Management Services

Effective Date:
January 1, 2015

Purpose:
Provide guidelines for the reimbursement of Chronic Care Management CPT® code 99490.

Scope:

  • All products are included, except
  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:
99490:
 Newly created (January 1, 2015) CPT code for chronic care management services.

Policy:
Horizon BCBSNJ shall not reimburse for the Chronic Care Management procedure code 99490.

It is Horizon BCBSNJ’s expectation that providers who manage and treat patients with multiple chronic conditions are adequately compensated for such services in the payments received for properly billed services related to the evaluation, management and treatment of those conditions and, therefore, chronic care management services are not separately reimbursable.

Given the foregoing, Horizon BCBSNJ’s reimbursement policy for CPT code 99490 is that it cannot be billed and will not be reimbursed separately under any circumstances.

It is worth noting that while CMS currently provides reimbursement for CPT 99490, it has established significant requirements that must be met in order for providers to receive reimbursement. These are detailed in the matrix below. It is also noted that providers who participate in Horizon BCBSNJ’s value based reimbursement programs do receive a care coordination fee for managing their patients’ care; providers managing patients with multiple chronic conditions should give consideration to entering into a value based arrangement with Horizon BCBSNJ.

Chronic Care Management Scope of Service Element/Billing Requirement Certified Electronic Health Record or other Electronic Technology Requirement
 Initiation during an AWV, IPPE, or comprehensive E&M visit (billed separately).  None
 Structured recording of demographics, problems, medications, medication  allergies, and the creation of a structured clinical summary record. A full list of  problems, medications and medication allergies in the EHR must inform the care  plan, care coordination and ongoing clinical care.  Structured recording of demographics, problems, medications,  medication allergies, and creation of structured clinical summary  records using CCM certified technology.
 Access to care management services 24/7 (providing the beneficiary with a means  to make timely contact with health care practitioners in the practice who have  access to the patient’s electronic care plan to address his or her urgent chronic  care needs regardless of the time of day or day of the week).  None
 Continuity of care with a designated practitioner or member of the care team with  whom the beneficiary is able to get successive routine appointments. None
 Care management for chronic conditions including systematic assessment of the  beneficiary’s medical, functional, and psychosocial needs; system-based  approaches to ensure timely receipt of all recommended preventive care services;  medication reconciliation with review of adherence and potential interactions; and  oversight of beneficiary self-management of medications. None
Creation of a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues. Share the care plan as appropriate with other practitioners and providers. Must at least electronically capture care plan information; make this information available on a 24/7 basis to all practitioners within the practice whose time counts towards the time requirement for the practice to bill the CCM code; and share care plan information electronically (other than by fax) as appropriate with other practitioners and providers.*
Provide the beneficiary with a written or electronic copy of the care plan and document its provision in the electronic medical record. Document provision of the care plan as required to the beneficiary in the EHR using CCM certified technology.
Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities. Format clinical summaries according to CCM certified technology. Not required to use a specific tool or service to exchange/transmit clinical summaries, as long as they are transmitted electronically (other than by fax).
Coordination with home and community based clinical service providers. Communication to and from home and community based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record using CCM certified technology.
Enhanced opportunities for the beneficiary and any caregiver to communicate with the practitioner regarding the beneficiary’s care through not only telephone access, but also through the use of secure messaging, Internet or other asynchronous non-face-to-face consultation methods. None
Beneficiary consent—Inform the beneficiary of the availability of CCM services and obtain his or her written agreement to have the services provided, including authorization for the electronic communication of his or her medical information with other treating providers. Document in the beneficiary’s medical record that all of the CCM services were explained and offered, and note the beneficiary’s decision to accept or decline these services. Document the beneficiary’s written consent and authorization in the EHR using CCM certified technology.
Beneficiary consent—Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month) and the effect of a revocation of the agreement on CCM services. None
Beneficiary consent—Inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month. None

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Deny procedure code 99490.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:

  • While reimbursement is considered, payment determination is subject to, but not limited to:
  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

CPT is a registered trademark of the American Medical Association

Policy 090_v1.0_07152015