Are doctors earning chronic care reimbursement?

By Eric Wicklund
02:41 PM

When the Centers for Medicare & Medicaid Services unveiled CPT code 99490 this past year, it was hailed as a first step in reimbursing providers for the use of telemedicine in chronic care management.

But are they taking advantage of this code?

"I think most physicians are missing it," said Michelle McKamy, a licensed clinician and director of special projects for SmartCCM. "They're finding it difficult to apply."

Based in Dallas, SmartCCM offers turnkey management services for healthcare providers seeking help with patient care management outside the office. They're one of roughly a half-dozen companies in the market, and poised to help providers who don't have the time or resources to connect all the dots.

But McKamy says not enough providers are even paying attention to 99490. She notes Aetna now covers the code – but as of yet, no providers have come to the insurer looking for reimbursement.

[Healthcare IT News Innovation Pulse column: Meet the new CMS code worth $17 billion -- annually.]

According to a primer put out by SmartCCM, "CPT 99490 reimbursement specifically incentivizes physicians to better manage patients with multiple chronic conditions, the 32 percent of our population that accounts for an overwhelming share of healthcare services such as prescriptions fills, home healthcare visits, office visits and the vast majority of general healthcare and Medicare spending as well."

"The 99490 Medicare guidelines cover 20 minutes of non-face-to-face chronic care management services per calendar month including establishing, implementing, revising and monitoring patients' care plans for patients with two or more chronic conditions," the primer continues. "The chronic conditions must be one of the CMS's observed 27 chronic conditions, must be expected to last for at least a year or until the death of the patient if that projected date is less than 12 months and, without proper management, the conditions must significantly jeopardize the patient's health, putting them at risk of functional decline, exacerbated health risks, or death."

According to McKamy, that's all well and good, but what doctor has the time or energy to chart every minute of every phone call made or text message or e-mail sent to check up on a patient meeting those standards?

All those minutes add up. McKamy echoes national estimates that have placed the amount of lost reimbursed income for a doctor who doesn't use CPT code 99490 at between $10,000 and $35,000 a year.

Reimbursing clinicians for providing chronic care management services isn't new. The American Medical Association, which devised the Current Procedure Terminology (CPT) code sequence, has long been supporting physicians with Codes 99381-99429, which cover certain visits, exams and counseling services, and Codes 99201-99215, which covers problem-oriented visits and management services. But all of those codes focus on face-to-face visits, whereas 99490 brings telehealth into the equation.

Likewise, CPT Codes 99487-99489 cover some of the same ground in preventive care and follow-up services, 99490 represents the first time that Medicare allows physicians to separately bill for reimbursement.

"It sounds simple, but it really takes a lot of time," said McKamy, citing national statistics that indicate the typical physician sees 2,500 patients a year, and can spend about 15 minutes a day on each case. "It's just a ton of burden to do the normal, everyday things."

And EMRs aren't helping. "Most are not designed to capture recorded minutes on the phone, for example," she said.

Despite the drawbacks, McKamy says 99490 is a step in the right direction, albeit a small one. "The benefit, aside from reimbursement, is in reaching out, calling in and checking on (patients) every month," she said. "It's important for the doctor to make that connection, because most of their chronic care patients won't even go to their annual wellness visits. It's important that the government is at least acknowledging that coordination is needed."

And she feels CMS won't stop with 99490.

"They are looking for innovation from the marketplace," she said, noting 99490 was developed after a series of successful transitional care and telehealth demonstrations. "They're looking aggressively at different technologies."

Others don't think they're looking fast enough. A coalition of organizations led by the American Telemedicine Association and the Personal Connected Health Alliance recently sent a letter to CMS seeking revisions to the proposed Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for CY 2016 that would, among other things, expand the qualifications for reimbursement under CPT Code 99490 and create new opportunities to reimburse providers for using remote patient monitoring technology.

"A well-established and ever-growing body of clinical evidence suggests that interoperable remote monitoring improves care, reduces hospitalizations, helps avoid complications and improves satisfaction, especially for the chronically ill," the letter states. "Use and provision of (remote patient monitoring) is restrained in Medicare by CMS' decision to provide no reimbursement for it. We urge CMS (and other federal payers) to (use) every opportunity to incorporate RPM and other proven eCare technology … to work towards a connected healthcare system."

Donald Voltz, an anesthesiologist, researcher, medical educator and entrepreneur, also feels that 99490 might be a step in the right direction, but a flawed one. Writing in HIT Consultant, he says the code is too difficult for most physicians to use, and should nevertheless be part of a more comprehensive chronic care management program.

"CMS requires at least 20 minutes are spent on care coordination activities each month in order to bill for this for patients enrolled in the program. Without a seamless component to log such activity, the efficiency of the overall process comes into question," he wrote. "A comprehensive CCM application must address the practice management side to account for and generate monthly reports of the CCM activities completed."