toward care management. There is a long list in the CPT manual of services that cannot be reported together with the care management codes, including care plan oversight, transitional care management, and end-stage renal disease services. The new chronic care management code is defined as follows: 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare 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. In order to be eligible for chronic care management, the patient must have at least two chronic medical conditions that put the patient at risk of “death, acute exacerbation/decompensation, or functional decline” and that are expected to last at least one year, or until the patient’s death. Also, the physician or practitioner must need to establish, implement, revise, or monitor a comprehensive care plan for the patient. Code 99490 can be reported only if this service requires at least 20 minutes of clinical staff time during the calendar month. Care management lasting less than 20 minutes in a month is not reported separately. In the 2015 Physician Fee Schedule Final Rule, CMS indicated that Medicare will accept code 99490 rather than requiring providers to use an HCPCS code for this service, as previously proposed. The complex chronic care management codes are defined as follows: 99487 Complex chronic care management services, 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; establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month. +99489 . . . each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, 34 HBMA BILLING • MARCH.APRIL.2015 per calendar month (list separately in addition to code for primary procedure) These codes require a higher level of service than 99490. In addition to the criteria listed above for chronic care management, there are also the following additional criteria: • Establishment or substantial revision of the comprehensive care plan (i.e., not just changing one medication or starting the patient on physical therapy) • Medical decision making of moderate or high complexity, as defined for E/M services • At least 60 minutes of clinical staff time during the calendar month Complex chronic care management services can be provided to either adult or pediatric patients, and the CPT manual provides examples of both. The typical adult patient is on three or more prescription drugs and may also be receiving other interventions, such as physical or occupational therapy. The typical pediatric patient is on three or more different types of interventions, such as drugs, nutritional support, or respiratory therapy. Additionally, typical patients meet one or more of the following criteria: • Need for coordination of a variety of specialists and services • Inability to perform activities of daily living, or inability to adhere to treatment plan without substantial assistance due to cognitive impairment • Care is complicated by psychiatric and other medical comorbidities • Need for social support, or difficulty accessing care CMS has designated the complex chronic care management codes as bundled services (status B in the Physician Fee Schedule RVU table). Advance Care Planning Two new codes have been created for advance care planning: 99497 Advance care planning, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate (continued from page 32)
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