The Department of Health and Human Services (HHS) Office of Inspector General (OIG) in early August 2021 published a report titled, ”Medicare Continues to Make Overpayments for Chronic Care Management Services, Costing the Program and Its Beneficiaries Millions of Dollars”. The OIG conducted this audit with the objective to determine whether payments made by the Centers for Medicare and Medicaid Services (CMS) to providers for noncomplex and complex Chronic Care Management (CCM) services rendered during calendar years (CYs) 2017 and 2018 complied with Federal requirements. This CCM OIG report is available at: https://oig.hhs.gov/oas/reports/region7/71905122.asp

Per CMS, Chronic Care Management addressing patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are eligible for CCM services.

Examples of chronic conditions include, but are not limited to, the following (from the 2019 CMS CCM MLN booklet/guidance):

• Alzheimer’s disease and related dementia
• Arthritis (osteoarthritis and rheumatoid)
• Asthma
• Atrial fibrillation
• Autism spectrum disorders
• Cancer
• Cardiovascular Disease
• Chronic Obstructive Pulmonary Disease
• Depression
• Diabetes
• Hypertension
• Infectious diseases such as HIV/AIDS

Physicians and the following non-physician practitioners may bill CCM services:

• Certified Nurse Midwives
• Clinical Nurse Specialists
• Nurse Practitioners
• Physician Assistants

In looking back a little in time, we see that in January 2015 CMS released a policy under the Physician Fee Schedule surrounding “Chronic Care Management”, for which these services were represented with several Current Procedure Terminology (CPT®) codes. Then in 2017 Medicare separated (unbundled) the CCM CPT codes for noncomplex and complex services. So, you can see that the CCM services are fairly new to having Medicare coverage. NOTE: CPT is a copyright of the American Medical Association (AMA).

Then in November 2019 the OIG published a CCM report titled, “Medicare Made Hundreds of Thousands of Dollars in Overpayments for Chronic Care Services” (A-07-17-05101). The goal of this particular audit was to determine whether physician and outpatient payments made by CMS for CCM services provided during calendar years (CYs) 2015 and 2016 complied with Federal requirements. The OIG stated in this report that errors occurred because CMS did not have adequate controls in place, including claim system edits, to identify and prevent overpayments. This 2019 report is available online at: https://oig.hhs.gov/oas/reports/region7/71705101.asp.

Per the newly released August 2021 OIG report, “Although scope of service and billing requirements are the same for noncomplex CCM as for complex CCM, the two types of services differ as to clinical staff time, medical decision-making, and care planning.” This report also focused on two different types of settings under which Medicare makes payments to health care providers. The first type of setting is a physician’s office. The second type is a hospital outpatient department. Hospital outpatient departments include off-campus provider-based departments that are subsidiary to and under the operational control of the hospitals that own them and are integrated into those hospitals for accounting purposes.

The OIG report continues to state: CMS requirements provide that physicians may bill for only one claim for CCM services for an individual beneficiary for each calendar month (service period). In addition, only one physician and one facility may bill for CCM services provided to a beneficiary during a service period (79 Fed. Reg. 67548, 67651 (Nov. 13, 2014); 81 Fed. Reg. 80170, 80364 (Nov. 15, 2016); HCPCS and CPT Codebook, CPT Codes 99490 and 99487)).

The OIG audit findings for overpayments regarding noncomplex and complex CCM services rendered during CYs 2017 and 2018, resulting in $1.9 million in overpayments associated with 50,192 claims. The following provides some additional overpayment details:

• 38,447 claims resulting in $1.4 million in overpayments for instances in which providers billed noncomplex or complex CCM services more than once for the same beneficiary for the same service period.
• 10,882 claims that resulted in $438,262 in overpayments for instances in which the same provider billed for both noncomplex or complex CCM services and overlapping care management services rendered to the same beneficiaries for the same service periods.
• 863 claims that resulted in $52,086 in overpayments for incremental complex CCM services that were billed along with complex CCM services that were overpayments.
• For these 50,192 claims, beneficiaries’ cost sharing totaled up to $540,680.

Although the OIG audit also found that CMS did not have adequate edits in place to help identify these CPT code overpayments, it’s the provider who is responsible to know and understand the coding rules and select all CPT codes accurately and avoid edits. In addition, the accuracy of the “Place of Service” or POS can make a difference in payment, thus, this is also an area to validate during an audit process. We must have our own checks and balances in place to ensure compliance is met.

CMS HCPCS code G2058 was the accepted add-on code for CCM for several years, then in 2021 G2058 was deleted and replaced with CPT 99439, with the same description. You will find these codes in your CPT codebook in the Evaluation & Management/Care Management Services section. The following lists the CCM basic and complex codes:

Basic CCM CPT Codes:

• 99490   Chronic care management services with the following requirement 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. First 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99439 New in 2021 (add-on) each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedures) Chronic care management services of less than 20 minutes duration, in a calendar month are not report separately.
• 99491 Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, 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.

Complex CCM CPT Codes:

• 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
  • Comprehensive care plan established, implemented, revised, or monitored
  • Moderate or high complexity medical decision making
  • first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
• 99489 (add on) each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

Note: The reimbursement is higher for the complex CCM CPT codes than the basic.

Don’t forget that there is a Medicare 60-day rule for refunding overpayments and the OIG did mention this in the August report. It’s important to ensure that every provider has a tracking system for all rebilling’s, both over and under payments. There also should be a process within the audit cycle that validates that the rebilling actually took place when there is a financial or quality impact. Also, remember that when the CPT codes for a given encounter are revised after an initial billing, the co-payment for the beneficiary should be checked, as there could be a refund needed, this also was mentioned in the OIG report. When auditing Medicare encounters, it’s important to call this out in the actual findings if there is a refund needed to the beneficiary as an action item. One important first step to take is to obtain the CMS Outreach document on Chronic Care Management, which has a wealth of great information; available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

It should be noted that an accurate ICD-10-CM diagnosis code is always essential for any healthcare encounter. So now is the time to audit some of your CCM encounters, whether physician office/clinic or hospital outpatient settings and utilize the OIG report and the CMS MLN. Discuss this service area with your auditing staff (both internal and external) and develop a plan to include auditing of these services soon.