Tough Questions: “Can you bill a patient who recently moved into a long-term care facility?”

In this post, we will go over a theoretical case involving a patient who was moved into a long-term care facility.  There are various issues we created for this case; however, the biggest problem was answering the question, “Can you bill Chronic Care Management when a patient like this moves into another nursing facility?”  Our research revealed the best possible answer on this subject. In short, what we found was that when you are billing for CPT code 99490 for CCM services provided in a skilled nursing facility or assisted living facility, you can bill for it if they meet specific requirements. Let’s dive into our research, findings, and rationale around this issue.

Per the CMS website, if all CCM billing requirements are met, and the facility is not receiving payment for Care Management services (for example the beneficiary is not in a Medicare Part A covered stay), practitioners may bill CPT 99490 for CCM services furnished to beneficiaries in skilled nursing facilities or assisted living facilities.  The place of service on the claim should be the billing location, i.e., where the billing practitioner would furnish a face-to-face office visit with that patient.

What this means is that, for any Chronic Care Management situation in which we would have a patient in a facility, if their stay is not a covered stay for Part A of Medicare, then the patient can be billed for CPT 99490. Of course, this patient must have already been receiving Chronic Care Management services and meet the following criteria:

  • Follow all the requirements and stipulations of code 99490
  • Meet 20 minutes for clinical staff time by your physician or your staff or qualified healthcare providers for the calendar month
  • Confirm that the patient still meets the criteria of two or more chronic conditions
  • Have a significant risk of death, acute exacerbation or functional decline
  • Have their comprehensive care plan established, implemented, revised or monitored

To clarify even further, you would have to have structured records of all your:

  • Demographics
  • Problems
  • Medications
  • Allergies
  • Medical Records
  • EHRs
  • 24/7 access to Care Management services
  • Continuity of care with a designated member of the care team
  • Systematic assessment of health needs
  • Receipt of preventative services
  • Electronic care plan accessibility
  • Management of care transitions between and among all the health care providers and settings
  • Coordination with the home and community-based clinical service providers as perceived as appropriate, enhanced communication opportunities for patients and caregivers and informed consent before providing Chronic Care Management services

As you know, this is quite a bit of information to manage. For more information on the entirety of the CPT code 99490, head on over to the CMS website and check out their fact sheet, CCM toolbox, and their frequently asked questions section, for reference.

Let’s get back to the story.  It is vital that we understand (1) exactly why the patient would be in this facility, (2) the purposes behind moving them, and (3) precisely what is being billed out. The last thing we want is to be in a situation where we would perform our 20 minutes of phone consultation with the patient (who is having an acute problem), then put in extra effort into coordinating the patient’s care, just to find out later that they moved into a facility and all the work is unbillable. It would be incredibly frustrating to spend resources to set up a care nurse to do a job like this and then find out that all the time and effort was spent on a patient who will not be billable at the end of the month.

When you are looking at EHR systems to handle situations like these, there are a few things you need to keep in mind, since they can be problematic but the one that often rises to the top, is of course, billing. Often times EHR systems do not bill out the 20 minutes of Chronic Care Management services the moment you complete it. Most Chronic Care Management module software bills out at the end of the month, instead of billing it out the day you perform the care. When the full month is completed, they typically create a batch for all Chronic Care Management patients and send out a billing batch at the very end of the month. This is easier to track of course, but it can also be a problem when you are in a situation like the one above. For example, under a system like this, if your patient goes into a care facility near the end of the month for whom you did some services at the beginning of the month, the system will attempt to bill the patient after they have already moved into the care facility that does not accept your system and thus you won’t get paid for the services you gave earlier that month.

There may or may not be a whole lot that you can do regarding that situation, depending upon what software programs you are using, but our recommendation is to look at these things from a billing standpoint so that you do not spend money on nurses for a particular patient for whom you will not be reimbursed.  There has been a lot of confusion about billing situations like this, but fortunately, in the past year, CMS has cleared up a lot of the issues surrounding Chronic Care Management services and how they can work with nursing or assisted living facilities.With our 30+ years of experience, RoseText is perfectly positioned to help you navigate not only situations like this but countless others. Don’t be left in the dark on serious issues and don’t let the success of your CCM system be left up to chance. Call or email RoseText today at 806-543-1435 or [email protected]  to set up a consultation. We can help you by taking some pressure off your team so you can give better care to your patients.

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