How to code CPT 99490?

1. How to code CPT 99490? Medical Billers and Coders

2. Chronic Care Management (CCM) services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. Medical Billers and Coders (MBC) have received multiple questions regarding “How to code CPT 99490”. To assist you in determining whether you are submitting this code correctly and documenting your services appropriately, please refer to the following questions and answers:

3. CPT for 99490 is defined as “clinical staff time directed by a physician or other Qualified Health Care Provider” Can you define what constitutes “clinical staff”? CMS Chronic Care Management (CCM) Fact states: “Eligible practitioners must act within their State licensure, the scope of practice, and Medicare statutory benefit. The CCM service may be billed most frequently by primary care physicians, although specialty physicians who meet all of the billing requirements may bill the service. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, therefore these practitioners cannot furnish or bill the service. However, CMS expects a referral to or consultation with such physicians and practitioners by the billing provider to coordinate and manage care.” TIP: Only one practitioner can furnish and be paid for the service during a calendar month.

4. What date of service should be used? Some carriers want just the last day of the month noted. Others want the entire date range of the month included. Example: September 1st through September 30th. Be sure to check with each carrier regarding their preference. CPT code 99490 cannot be billed during the same calendar month as CPT codes 99495–99496 (Transitional Care Management), Healthcare Common Procedure Coding System (HCPCS) codes G0181/G0182 (home health care supervision/hospice care supervision), or CPT codes 90951–90970 (certain End-Stage Renal Disease services). Claims should be submitted with the date of service on which the 20-minute requirement was met. TIP: Time must be documented as either total time OR start/stop times

5. Since this is a non-face-to-face code, does “incident to” apply, or will this be covered under general supervision? In the Medicare Physician Fee Schedule, the physician supervision indicator for CPT code 99490 is listed as “09,” which is defined in the CMS Medicare Claims Processing Manual as “concept does not apply.” TIP: The services counted toward the 20 minutes must be provided by clinical staff.

6. Can 99490 be billed for inpatients? Possibly. The place of residence could be an assisted living or nursing home facility. You will need to find out how the patient is registered. If Part A is being received by the facility, then you cannot bill CCM services. You should instead use codes such as 99307, 99308, and other home health certification codes.

7. Do you have a list of recommended chronic conditions that supports the requirement for patients to be eligible? Examples of chronic conditions include, but are not limited to: Alzheimer’s disease and related dementia; Arthritis (osteoarthritis and rheumatoid); Asthma; Atrial fibrillation; Autism spectrum disorders; Cancer; Chronic Obstructive Pulmonary Disease; Depression; Diabetes; Heart failure; Hypertension; Ischemic heart disease; Osteoporosis TIP: Documentation should support that the patient’s chronic conditions; they must “place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”

8. There is a requirement that patients be able to reach providers 24/7. Does an answering machine meet the expectation? No. An answering machine does not meet this requirement. Access to care is a key requirement in order to submit claims for chronic care management. Providers must “ensure 24-hour-a-day, 7 day-a-week access to care management services,” and patients must have “a means to make timely contact with health care practitioners in the practice who have access to the patient’s health record to address his or her chronic care needs.” Will commercial carriers pay for this code? Check with your local carriers. They may or may not. It’s possible they may pay in the future too as CCM gains traction.

9. Do Medicare Advantage plans pay for 99490? At a minimum, provide them with what is required by Medicare. They should pay unless they are a capitated Advantage plan. Although, some Advantage plans do offer and go beyond the minimum requirements of Medicare.

10. Does patient consent have to be obtained each month? Informed patient consent only needs to be obtained once, prior to providing the first CCM service. However, if the patient changes providers and the new provider will bill for CCM, then the patient must sign a new consent with that provider.

11. Is an annual wellness visit (AWV) or “Welcome to Medicare Visit” required before CCM services can be billed? Yes. CMS requires an AWV, welcome visit, OR comprehensive E/M before CCM services can be billed.

12. Are there any codes that cannot be billed in the same month as 99490? Yes. Those codes include Transition Care Management – 99495, 99496; Home Healthcare Supervision – HCPCS G0181; Hospice Care Supervision – HCPCS G9182; Certain ESRD Services – CPT 90951-90970.

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