CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy — Transitional Care, Chronic Care and Complex Chronic Care Management

Governs payment and coverage guidelines for Transitional Care Management (TCM), Chronic Care Management (CCM), and Complex Chronic Care Management (CCCM) services for Blue Cross Blue Shield - Rhode Island members, including distinctions for BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy — Transitional Care, Chronic Care and Complex Chronic Care Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2019

Next Review DateN/A

Key ActionReport TCM services once per member during the 30-day TCM period; only one health care professional may report TCM services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-dayTCM period

99495/99496TCM codes covered

99490/99487/99489CCM/CCCM codes

oneTCM reporting frequency

Coverage and Reimbursement Criteria

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Coverage criteria

Coverage and reimbursement rules differ between BlueCHiP for Medicare and Commercial products as follows.

BlueCHiP for Medicare: Transitional Care Management (TCM) services are covered and separately reimbursed when payment guidelines are met; the 30-day TCM period begins on the date of discharge to home from specified settings and continues for the next 29 days.

BlueCHiP for Medicare: Eligible discharge settings include inpatient acute care hospital, long-term care hospital, inpatient psychiatric hospital, skilled nursing facility, hospital outpatient observation or hospitalization partial, inpatient rehabilitation facility, and partial hospitalization at a community mental health center.

BlueCHiP for Medicare: Report TCM services once per member during the TCM period; only one health care professional may report TCM services.

BlueCHiP for Medicare: The required face-to-face visit is part of the TCM service and must occur within the timeframes specified by the CPT code filed (99495: within 14 calendar days; 99496: within 7 calendar days). This face-to-face visit should not be reported separately.

BlueCHiP for Medicare: Codes 99495 and 99496 are covered and separately reimbursed when their required elements are met (communication with patient/caregiver within 2 business days of discharge and the specified level of medical decision making).

BlueCHiP for Medicare: CCM and CCCM codes (99490, 99487, 99489) are covered but not separately reimbursed for all providers.

Billing restrictions (BlueCHiP for Medicare): TCM may not be billed if any portion of the 30-day TCM falls within the postoperative global period for a procedure billed by the same practitioner; when billing 99495/99496 during the TCM period, do not also report HCPCS G0181/G0182 (home health/hospice supervision), care plan oversight services, or ESRD CPT codes 90951-90970.

Commercial Products: TCM, CCM, and CCCM services (99495, 99496, 99490, 99487, 99489) are covered but not separately reimbursed for all providers; the same required elements (communication within 2 business days, face-to-face within specified days, and required levels of medical decision making or clinical staff time) apply.

Commercial Products: CCM/CCCM minimum monthly clinical staff time requirements are: 99490 = at least 20 minutes per calendar month; 99487 = 60 minutes per calendar month; 99489 = each additional 30 minutes per calendar month (listed separately in addition to primary CCCM code).

Operational notes: The same health care professional may discharge the member and bill TCM, but the required face-to-face visit may not occur on the same day discharge management services are reported; report reasonable and necessary E/M services (other than the required TCM face-to-face) separately.

CPT Codes and Billing Rules

TCM codes (BlueCHiP for Medicare) - covered and separately reimbursedCPTCovered

99495	Transitional Care Management Services — moderate complexity; communication within 2 business days; face-to-face within 14 calendar days of discharge
99496	Transitional Care Management Services — high complexity; communication within 2 business days; face-to-face within 7 calendar days of discharge

TCM/CCM/CCCM codes (Commercial) - covered but not separately reimbursedCPTNot Covered

99496	Transitional Care Management Services — high complexity; communication within 2 business days; face-to-face visit (Commercial: covered but not separately reimbursed)
99495	Transitional Care Management Services — moderate complexity; communication within 2 business days; face-to-face within 14 calendar days (Commercial: covered but not separately reimbursed)
99490	Chronic care management services — at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month (Commercial: covered but not separately reimbursed)
99487	Complex chronic care management services — 60 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month (Commercial: covered but not separately reimbursed)
99489	Each additional 30 minutes of clinical staff time for complex chronic care management services (Commercial: covered but not separately reimbursed)

CCM/CCCM codes (BlueCHiP for Medicare) - covered but not separately reimbursedCPTNot Covered

99487	Complex chronic care management services — 60 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month
99490	Chronic care management services — at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month
99489	Each additional 30 minutes of clinical staff time for complex chronic care management services (list separately in addition to primary procedure)

CCM/CCCM minimum monthly clinical staff time

99490At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month

9948760 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month

99489Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (listed separately in addition to primary code)

TCM reporting frequency

Reporting frequencyOnce per member during the 30-day TCM period

TCM period length30-day period beginning on the date of discharge

Reporter limitOnly one health care professional may report TCM services during the period

Provider Actions and Billing Notes

Note

Medical criteria and prior authorization

Not applicable

Billing Rule

TCM reporting limits — single report and single reporter

Report TCM services once per member during the 30-day TCM period; only one health care professional may report TCM services.

The 30-day TCM begins on the date the member is discharged and continues for the next 29 days.
Report reasonable and necessary E/M services (other than the required face-to-face visit) separately.
The face-to-face visit required by the CPT code is part of the TCM service and should not be reported separately.

Definitions

Transitional Care Management (TCM)

DefinitionTransitional Care Management (TCM) — services provided following discharge from specified settings to home during a 30-day period, with required communication and face-to-face elements as defined by CPT codes 99495 and 99496

Covered settingsApplies when discharged from inpatient acute care hospital, long-term care hospital, inpatient psychiatric hospital, skilled nursing facility, hospital outpatient observation, inpatient rehabilitation facility, or partial hospitalization at a community mental health center

Key CPT codes99495 (moderate complexity; communication within 2 business days; face-to-face within 14 days), 99496 (high complexity; communication within 2 business days; face-to-face within 7 days)

Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM)

DefinitionChronic Care Management (CCM) and Complex Chronic Care Management (CCCM) — ongoing management services for patients with multiple chronic conditions requiring a comprehensive care plan and monthly clinical staff time directed by a physician or other qualified health care professional

Primary CPT codes99490 (CCM), 99487 (CCCM), 99489 (additional 30-minute increments for CCCM)

Coverage noteFor BlueCHiP for Medicare these codes are covered (99490, 99487, 99489); for Commercial products they are referenced as covered but not separately reimbursed