Half of all American adults — about 117 million people—suffer from one or more chronic health conditions. Indeed, seven of the top 10 causes of death in the U.S. today are a result of chronic conditions like Diabetes, Alzheimer’s and Cardiovascular disease. As a result, Chronic Care Management (CCM) has taken the spotlight in the healthcare industry and new Medicare payment guidelines reflect the new focus on CCM.
CPT Code 99490
The Centers for Medicare and Medicaid Services (CMS) recognize CCM as a critical component of primary care that contributes to better patient health while reducing healthcare costs overall. So beginning in January 2015, CMS established CPT code 99490 as an incentive to foster CCM and to help cover the costs of chronic care management. The new code allows payment at an average of ~$40 per beneficiary per month for services performed for Medicare beneficiaries.
The good news is that CPT 99490 will significantly broaden Medicare payments for remote patient monitoring of chronic conditions. In order to be eligible the patient must have two or more significant chronic problems that pose a real risk to the patient’s health and well-being. The practice must implement an ongoing care plan that addresses these conditions, and a clinical staff member must spend at least 20 minutes during a calendar month coordinating care and communicating with the patient.
Historically, Medicare has provided limited coverage for this type of service and the new code could result in a profitable advantage for providers, especially smaller physician practices and / or community-based facilities that work with chronically ill patients. These providers now have a financial incentive to promote CCM among their constituents and to retain "control" over those patients; once they refer on to an enterprise healthcare system they stand to potentially lose control as the PCP.
But there is some bad news, too, which is that CPT 99490 may unwittingly provide a disincentive for larger enterprise healthcare organizations when it comes to CCM. Most hospitals and clinics are considered a “facility” and, therefore, are not eligible for payment under the new code. Complex billing systems can work around the red tape but it’s a nightmare to administer. The fact that many physicians are actually paid employees of the enterprise works to cloud the administrative waters even further. The truth is that it would be more profitable for these larger organizations to simply release the patient and readmit if/when the condition recurs.
If your practice is a direct, patient-centered practice that is already providing case management for a group of chronically ill patients, you are in a great position to benefit from the new CPT 99490 code.
It will take more time to sort out the implications of the new code for larger enterprise organizations, however; and more thoughtful and technology-enabled strategies will be needed in order to use the code advantageously. In the meantime, look for providers and partners with the right combination of technologies, capabilities, vision and experience that will help you employ meaningful strategies regarding Chronic Care Management and CPT 99490.