CMS: You can bill CCM in Non-Part A Nursing Facility Stays

Over the last year, AMDA - The Society for Post-Acute and Long-Term Care Medicine has asked the Centers for Medicare & Medicaid Services (CMS) to clarify whether the Chronic Care Management (CCM) Current Procedural Terminology (CPT) code was billable in nursing facilities. The original descriptor per AMA CPT for CCM stated that “these [CCM] management and support services are provided to patients who reside at home or in a domiciliary, rest home, or assisted living facility” which left confusion about billing the code in skilled nursing facility and nursing facility (SNF/NF) settings. However, CMS has recently updated a set of frequently asked questions (FAQs) answering questions about billing CCM services to the Physician Fee Schedule  (PFS) and the Hospital Outpatient Prospective Payment System (OPPS) under CPT code 99490.

Of note in the revisions is the question: “Can I bill CPT 99490 for CCM services provided to beneficiaries in skilled nursing facilities, nursing facilities or assisted living facilities?”

"If all the CCM billing requirements are met and the facility is not receiving payment for care management services (for example, the beneficiary is not in a Medicare Part A covered stay), practitioners may bill CPT 99490 for CCM services furnished to beneficiaries in skilled nursing facilities, nursing facilities or assisted living facilities. The place of service (POS) on the claim should be the billing location (i.e., where the billing practitioner would furnish a face-to-face office visit with the patient)."

In order to bill the code the billing practitioner must still fulfill all of requirements of the code which include:
99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care 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 place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
• comprehensive care plan established, implemented, revised, or monitored

CMS further clarifies these requirements to include: 

• Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record, using a certified Electronic Health Record;
• 24/7 access to care management services;
• Continuity of care with a designated member of the care team;
• Systematic assessment of health needs and receipt of preventive services;
• Electronic care plan accessible to all individuals in practice providing CCM services with written or electronic copy to patient;
• Management of care transitions between and among health care providers and settings;
• Coordination with home and community-based clinical service providers as appropriate;
• Enhanced communication opportunities for patient and caregiver; and
• Informed consent prior to providing CCM services

CMS has also issued a fact sheet further outlining ways to bill the code. We urge practitioners to review these materials carefully when deciding whether or not they can bill CCM in SNF or NF settings.  

The Society would like to hear from you if you are planning to bill CCM in SNF or NF settings. Please send us an e-mail at publicpolicy@paltc.org and let us know about your experience. 

To read the entire FAQ click here.