Q. What are the details and requirements for billing a 99490 code?
A. 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
Q. How does billing the Add-On Code 99439 work?
A. CMS recognized there is a significant gap of time and resources between 99490 and 99487, therefore they created the 99439 code. 99439 is meant to reimburse clinicians for all 20-minute increments of time spent on patients, after the first 20-minutes. This first 20-minutes is still coded as 99490.
- Up to two 99439 codes can be added to 99490 in a month.
- Like 99490, 99439 cannot be used in conjunction with 99487, 99489, or 99491.
Q. How much does CCM cost to the patient?
A. With the patient being a Medicare beneficiary, Medicare will pay for this service, once the patients annual deductible is met. Their secondary insurance should cover the 20% ($10-$14) copay, alleviating any out of pocket cost to the patient. As the billing practitioner, you should be filing both the Medicare and secondary insurance for these services.
- There are 3 secondary insurances who will not cover the copay for CCM. There insurances are Humana, Tricare and Optima Health. Any patients who have one of these as a secondary insurance will be liable for the $8 copay for every completed Chronic Care Management exam. *Patients must have Medicare as their primary insurance.
- Only one in 10 beneficiaries relies solely on the Medicare program for health care coverage. The rest have some form of supplemental converge to help with medical expenses, so approximately 90% of patients may not have to pay out of pocket for the co-pays.
Q. Do Medicare Advantage (MA) plans reimburse for CCM? What about commercial payers?
A. A Medicare Advantage plan is required to offer its enrollees at least traditional Medicare benefits, which now will include CCM. It seems reasonable to assume that an MA plan will pay for CCM just as it now pays for other physician services. Whether commercial payers will pay for CCM remains to be seen, although the fact that CMS is paying for this service makes it more likely.
Q. How do I reconcile the CCM patients I was invoiced for by HealthWatch?
- Login to your database and go to the Billing portal
- From the billing portal, on the left-hand side, under “Insurance” click “Billing Query”
- Under search criteria, “Claim,” in the “Code(s)” field, enter “99490,” then under the “Procedure” section, set your “Post Date” based on your invoice month (example below would be an invoice from August)
- Once your criteria is set, click the magnified glass in the top toolbar to bring back your search results.
- The total number of rows displayed in the bottom left hand corner of the search screen should match your invoice number, so in this example, you would have been invoiced for 2006 patients.
- If for some reason your invoicing is off, please contact your HealthWatch point of contact.
Q. How do I handle patient billing disputes?
A. At times, a patient may feel as if they were billed incorrectly for a CCM service (i.e. did not understand there would be a fee, feel they did not consent, etc.). If a patient communicates with the practice about disputing their CCM charge, it is at the discretion of the practice to refund the patient. If the practice would like more information to make this decision, they should follow these steps:
- Gather the patient’s information, their dispute, and submit a review form: https://app.smartsheet.com/b/form/dfacac83646b42729d9ed9e310691ab9
- The form will be submitted to the HW management team where they will evaluate the patients phone encounters, CCM medical notes, exam history, and listen to any recordings related to the billing concern.
- The HW management team will then connect back with the practice to deliver findings on the dispute. The practice can then reconnect with the patient and decide whether to refund the claim.
- If the HW team finds the patient received care coordination incorrectly at the fault of the HW staff, the practice will be notified, and they will receive a credit from HealthWatch on their next invoice. The practice will be credited their contracted rate.
Q. How do I handle my practice claim disputes/questions?
A. If a practice receives a CCM claim denial and would like HealthWatch to review the denial, or potentially seek credit for the denial, they should follow these steps:
- The practice has 60 days from the CCM date of service to dispute any claims and/or invoicing issues, this can be referenced on your HealthWatch monthly invoice:
- Input patient’s information, their dispute/claim denial reason and submit a review form: https://app.smartsheet.com/b/form/dfacac83646b42729d9ed9e310691ab9
- The form will be submitted to the HW management team where they will evaluate the patients phone encounters, billing, CCM medical notes, exam history, and listen to any recordings related to the billing concern.
- The HW management team will then connect back with the practice to deliver findings on the claim denial.
- The HW team will work with the practice to explain the denial reasoning, and assist them in getting the claim updated to be resent if applicable
- The practice should then reconnect with the patient and decide whether to refund the claim or reprocess the claim if it was a failed claim and it can be resubmitted.
Q. Why may a credit need to be rendered?
A. Below are a few examples a credit may be provided to the practice from HealthWatch:
- Patient is deceased – it is (unfortunately) common for a patient to pass away while they are enrolled in CCM and for the HealthWatch team to not be notified until after they have sent the patient care coordination via mail. Patients receive monthly calls, and if they do not answer their routine monthly call, our HealthWatch team will send them their care coordination in the mail. Once the practice is notified of the passing, they should alert the HealthWatch immediately so the patient can be discharged.
- Patient was hospitalized – similar to the deceased example, patients may become hospitalized while enrolled in the CCM program. Once the HealthWatch team is notified, the patient will be discharged, or placed on hold, and the patient can be credited for the care coordination they received while in the hospital.
- Patient was enrolled in another CCM program – our care coordination team always asks our patients if they are enrolled in another CCM program, but sometimes the patient does not understand they’re in another program or they were not informed. If a patient is enrolled in two CCM programs, the practice claim may be denied and listed as “too many frequency of services.” In this case we would credit the practice for the HealthWatch CCM charge and discharge the patient from our program.