How to utilize CPT 99490 to increase revenue opportunities

July 11, 2017 |  EHR, How to, Population Health, Revenue Cycle

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In early May, the Advisory Board released its Annual CEO Survey of 183 CEO’s about their top concerns for 2017. Interestingly, many of the concerns were related to the subject of Population Health and the healthcare industry’s movement from volume to value. Do any of these results or  concerns sound familiar to you or your organization?

  • Improving ambulatory access
  • Innovative approaches to expense reduction
  • Boosting outpatient procedural market share
  • Minimizing unwarranted clinical variation
  • Controlling avoidable utilization
  • Exploring diversified, innovative revenue streams

Source: Advisory Board Annual CEO Survey

With organizations entering into quality-based reimbursement models like ACO’s, Patient Centered Medical Homes, and Shared Savings agreements, healthcare is moving to the ambulatory environment as organizations look to deliver proactive and preventative care at the appropriate utilization, helping reduce avoidable emergency department visits and hospitalizations.

So it makes sense that organizations are looking for ways to provide better ambulatory access, boost outpatient procedural market share, and control avoidable utilization as these are paramount to the successful deployment of population health programs and initiatives.

We’re also finding in our conversations with C-level executives, that organizations are looking to leverage technology and tools to become more efficient. It’s refreshing to see that most organizations are embracing Lean Six Sigma process improvement approaches to eliminate waste and promote efficiencies in Revenue Cycle, Clinical Documentation, Supply Chain, and throughout other departments across the enterprise. With declining reimbursements and penalties for 30-day readmissions and hospital acquired conditions, organizations are doing everything they can to reduce expenses. In my conversations, I have also seen an uptick in organizations looking to take advantage of new revenue opportunities, such as annual wellness visits, transitional care management, and most notably chronic care management CPT 99490.

Recently, I was meeting with an organization that had deployed an impressive chronic care management program. They had 1,200 patients within the program with a care coordinator responsible for 200 patients each. With this one CPT code, they were able to generate $650,000 in revenue.

The uptick in interest and utilization of the program can be explained through recent CMS campaigns looking to increase adoption as well as organizations attempting to be a bit creative when researching additional revenue streams. Organizations are finding that this program helps combat declining reimbursement, increasing costs, and a shifting industry that is pointed toward a fee-for-value reimbursement model.

Chronic Care Management CPT 99490: A New Revenue Opportunity

Chronic Care Management (CCM) CPT 99490 is a program pertaining to Medicare fee-for-service patients that incentivizes the delivery of chronic care management services.

There are requirements that organizations must meet to receive reimbursement through the program. They include:

  • At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
  • 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 a significant risk of death, acute exacerbation/decompensation or functional decline
  • Comprehensive care plan established, implemented, revised or monitored.

Once the requirements are met, the reimbursement per patient per month is $43.

The program itself is significantly underutilized. According to the Advisory Board, “of the 35 million Medicare beneficiaries eligible to receive CCM services, claims were submitted for only 100,000 or so beneficiaries in the first year, and only 0.2 percent of those were eligible.” CMS views this program as “a critical component of primary care that contributes to better health and care for individuals,” according to their website.

MEDITECH’s Chronic Care Management Registry

With such a high volume of patients in the program, it’s important to leverage EHR technology to automate as much as possible to help reduce errors and omissions. MEDITECH has created Chronic Care Management specific queries that can be pulled onto any existing registries which automates the Chronic Care Management process. From there, you can document how much CCM service time each patient has been given and the system will add the time up monthly if multiple calls have taken place.

At the end of the month, you’ll be alerted to each patient and whether or not they have documented the required 20 minutes. If they have, the patient’s name turns green and the program drops the charges at the end of the month’s quote of billing.

It is important to note that it is not as easy as flipping a switch and deciding to start billing. Organizations looking to start a program will have to hire the resources as well as deploy processes and workflows, and perform a total cost of ownership analysis. However, according to the Health Care CEO study, it seems as though CPT 99490 and other revenue opportunities will continue to be key drivers as organizations look to thrive in the changing healthcare paradigm.

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Written by Ken Laliberte, Solutions Manager for Analytics and Population Health, MEDITECH

Ken Laliberte is responsible for meeting with healthcare leaders to discuss how MEDITECH's solutions and services will allow them to excel in an industry in the midst of a paradigm shift from volume to value. He fervently believes that true transformation requires organizations to not only obtain technology and software, but to also address buy-in and processes. Ken enjoys exploring creative solutions organizations can deploy to standardize and enhance workflows for increased efficiencies and discussing strategies to promote engagement and buy-in.
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