Advance Care Planning Services

Question

CPT has created two new codes for advance care planning CPT 99497 and 99498, both effective January 1, 2015 how much is Medicare paying for this service?

Answer

Unfortunately Medicare for CY 2015 has decided that these services are paid using existing CPT codes such as E&M services, therefore these two codes if billed have no Medicare payment. For Medicare if you provide these services continue to use your E&M codes to report. If you are billing to third party payers, check with those payers as they may have different payer policies from Medicare.

Complex Chronic Care Services (CCM)

Question

Can all physicians including specialists’ bill the CCM services, or are they just for primary care physicians?

Answer

Yes, any physician or qualified health care professional meeting the reporting requirements are able to bill for CCM. Physicians treating patients with at least two or more chronic conditions could be eligible to bill the codes. Only one physician per month may report these services.

Question

For a Medicare patient, since Medicare is only paying for the single CPT code 99490, if a patient meets the elements of 99487 or a combination of 99487 and 99489 can I bill the 99490 rather than the higher complexity code?

Answer

Yes, similar to how Medicare is not recognizing the consultation codes and they instruct providers to use other E&M codes in their place we would see no difference for these codes, therefore CPT would defer to the payer policies and allow billing the less intense code when Medicare is not recognizing the higher complexity services.

Question

Are there only certain diagnoses that CCM codes can be reported with?

Answer

There is not a defined list of diagnosis codes that meet the requirements of CCM. What is required is that the chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline and that management requires a care plan. There has been no guidance as to whether claims will require two or more diagnoses. Some examples of patients with two or more of the following conditions that may be appropriate for the use of chronic care management services:

• congestive heart failure
• COPD
• poorly controlled diabetes mellitus
• neurocognitive disorders including Alzheimer’s disease, dementia and Parkinson’s disease
• stroke with late effects that place the patient at risk for falls, fractures and aspiration pneumonia

*Please note this is not an all-inclusive list.

Question

Does a specialist such as a neurologist or pulmonologist have to manage all of the chronic conditions in order to utilize the CCM code? Or is it sufficient if he/ she manages one condition and the other conditions impact the management of the one condition?

Answer

The specialist has to manage all of the patient’s chronic conditions to report CCM. The specialist may be the individual who is overseeing all care management and coordination. Of note, only one physician is allowed to bill and be paid for this service during any one calendar month.

Question

Can an E/M visit be billed at the same time as the CCM code?

Answer

Yes, but any clinical staff time on a day when the physician reports an E/M service may not be counted toward the care management service code. E/M services may be reported separately by the same physician (or other qualified heath care professional) during the same calendar month.

Question

Will the patient be required to pay copay each month, when the CCM service is reported?

Answer

Yes, the patient must indicate to the physician he/she wants chronic care management services, and is responsible for the co-insurance. It is the responsibility of the health care provider to notify the patient of the co-insurance and document consent for the service. Medicare has not yet indicated if signed consent is required each month or for a series of months. We will ask CMS for further guidance.