State & FederalMedicare AdvantageJuly 31, 2020

Waived copays, deductibles and coinsurance for CCM, complex CCM and TCM

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

To support improvement of health outcomes for our members, cost-sharing requirements (copays, deductibles and coinsurance) are not applied to chronic care management (CCM) and transitional care management (TCM) services for Medicare Advantage plans (with the exception of Dual-Eligible Special Needs Plans [D-SNPs]), effective for dates of service on and after September 1, 2019.

 

CCM, complex CCM and TCM services will be allowed per Medicare coverage guidelines. Members and providers must still meet criteria set by Medicare. These services require advanced consent from the member, which must be documented in the patient’s medical record.

 

The following services are included:

Initiation of CCM or complex CCM:

G0506 — Comprehensive assessment and care planning by the physician or other qualified health care professional for patients requiring chronic care management services

CCM:

99490  — CCM 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

99491 — CCM 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:

99487 — Complex CCM 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
  • Establishment or substantial revision of a comprehensive care plan
  • Moderate or high complexity medical decision making
  • 60 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month

99489  — Complex CCM 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
  • Establishment or substantial revision of a comprehensive care plan
  • Moderate or high complexity medical decision making
  • 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)

TCM:

 99495 — Transitional care management services with the following required elements:
  • Communication (direct contact, telephone or electronic) with the patient or caregiver within two business days of discharge
  • Medical decision making of at least moderate complexity during the service period
  • Face-to-face visit within 14 calendar days of discharge

99496 — Transitional care management services with the following required elements:

  • Communication (direct contact, telephone or electronic) with the patient or caregiver within two business days of discharge
  • Medical decision making of high complexity during the service period
  • Face-to-face visit within seven calendar days of discharge

 

EBSCRNU-0117-20 June 2020

510548MUPENMUB

 

PUBLICATIONS: August 2020 Empire Provider News