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Know your provider type and bundled services.

Oncology stands out as a specialty not only for its critical role in patient care but also for the extensive, often unseen, services it provides to cancer patients. This presents an opportunity for healthcare providers to strategically report certain care management services, thereby recouping some of the costs associated with patient care.

By properly leveraging the care management codes, oncology practices can enhance their reimbursement strategies. Here’s a review of these services to determine if reporting these codes is a good idea for your organization and patients.

Get to Know CCM

Chronic care management (CCM) and principal care management (PCM) services encompass a variety of activities, such as managing referrals, medication refills, completing patient forms, telephone calls with the patient or caregiver, and obtaining prior authorizations.

The CCM codes are for patients that have two or more chronic conditions that will last at least 12 months or until the death of the patient. Before you can report a CCM code, the billing provider must conduct an initiating visit if they have not seen the patient within the previous 12 months, which you will report with G0506 (Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)). The service may be reported separately from the other CCM codes. 

Typically, during the initial visit, the provider will review the services the patient may receive. The provider must also obtain the patient’s consent, as it is a requirement. The consent may be written or verbal but must be documented in the medical record. The provider should also create a comprehensive care plan, which will include documentation of the conditions for which CCM services are being provided, treatment goals, medical management, any community and social services provided and ordered, expected outcome, and much more. The billing provider must periodically review and revise the care plan when appropriate, and they must provide a copy of the care plan to the patient. 

Once the billing provider has completed the initiating visit, you may report monthly services using the following codes depending on the cumulative time spent during the month and based on the type of provider who performed the services: 

• If clinical staff performed the services under the direction of a physician or qualified healthcare professional, you’ll report 99490 (Chronic care management services …) for the first 20 minutes during the month. For each additional 20 minutes of clinical staff time, you’ll report +99439 (… each additional 20 minutes of clinical staff time … per calendar month) in conjunction with 99490.
• If the physician or qualified healthcare professional performed the services, you’ll report 99491 (Chronic care management services … provided personally by a physician or other qualified health care professional …) for the first 30 minutes during the month, and +99437 (… each additional 30 minutes by a physician or other qualified health care professional, per calendar month …) in conjunction with 99491 for each additional 30 minutes of clinical staff time.

Use PCM for 1 Condition

Unlike CCM, PCM services involve the management of a single chronic condition that is expected to last at least three months. Like CCM, PCM services also require patient consent, a comprehensive care plan, and an initial visit; however, G0506 is not applicable for PCM services.

Like CCM, PCM billing depends on time and provider type. You can report clinical staff time under the direction of the physician or QHP with 99426 (Principal care management services …) for the first 30 minutes per calendar month in conjunction with +99427 (Principal care management services …) for each additional 30 minutes per calendar month. 

For physician or QHP time, you’ll use 99424 (Principal care management services …) for the first 30 minutes per calendar month, and +99425 (Principal care management services …) in conjunction with 99424 for each additional 30 minutes per calendar month.

Know When TCM Is Appropriate

Transitional care management (TCM) services are essential for patients who are transitioning from inpatient care back into a community setting. These patients often have complex medical and/or psychosocial conditions that require a moderate or high level of medical decision making (MDM). The rules for reporting TCM services are complex, and meticulous documentation and follow-up are necessary for billing them. 

When a patient is identified as needing TCM services, a clinical staff member of the billing provider’s care management team who can address the patient’s medical status must initiate interactive contact with the patient within two business days of the patient being discharged from the inpatient setting. This can be by phone, email, or in person.

If the clinical staff member cannot make initial contact with the patient, the billing provider can still bill for TCM if the billing provider can meet all the other TCM criteria. The billing provider must then reconcile and manage the patient’s medications before a face-to-face visit. 

For a patient whose condition satisfies the elements of moderate-level MDM and whose face-to-face visit occurs within 14 calendar days of discharge, you should report 99495 (Transitional care management services …). But for a patient whose condition satisfies the elements of high-level MDM and whose face-to-face visit occurs within seven calendar days of discharge, you’ll report 99496 (Transitional care management services …).

Note: During the calendar month, the billing provider can count such non-face-to-face services as communication with patients and caregivers; identifying community and health resources; establishing referrals; providing education to patients, family, and caregivers; and much more toward TCM.

Navigate PIN Services

Principal illness navigation (PIN) services cater to patients with one or multiple serious high-risk conditions that are expected to last at least three months and which poses a significant risk of hospitalization, functional decline, acute exacerbation or decompensation, or death.

To report PIN services, the billing provider is required to create a disease-specific care plan and obtain patient consent, while a patient navigator or certified peer specialists under the direction of a physician or other practitioner must meet with the patient for an initiating visit. The time requirement for the monthly service code is much higher than CCM and PCM services.

Medicare has created two G codes for reporting these monthly services: G0023 (Principal illness navigation …) is for the first 60 minutes of PIN services per month provided by certified or trained auxiliary personnel under the direction of a physician or other practitioner, while add-on code G0024 (Principal illness navigation …) is for each additional 30 minutes of time during the month and is reported in conjunction with G0023. Monthly support services that you may consider for PIN include health education, care coordination, facilitating access to community and social services, referrals, building patient self-advocacy skills, and much more.

Remember: The Centers for Medicare & Medicaid Services (CMS) requires personnel providing PIN services to have specific knowledge and training, which is outlined in the , where PIN services were first introduced.

Educate Yourself Further on Care Management Service Billing

The CMS Medicare Learning Network (MLN) features downloadable booklets for the different care management services, including , which includes information on PCM, , and . Each one contains detailed instructions on the requirements for billing the codes.

Remember: Each of these services include behind-the-scenes support that oncology practices commonly provide to patients who are under the provider’s care. By understanding and utilizing care management service codes, oncology practices can better manage financial resources while continuing to provide quality patient care.

Nikki Taylor, MSHCI, COC, CPC, CPCO, CPMA, CRC, ÐÇ¿ÕÈë¿ÚApproved Instructor, McKesson