Wound/ulcer management physicians and other qualified healthcare professionals (QHPs) often complain when they cannot report an evaluation and management code during the same encounter in which they performed a minor surgical procedure. These complaints stem from the amount of time that the physicians/QHPs and their clinical staff spend creating and managing a care plan that addresses one or more chronic illnesses, educating patients and their caregivers, and coordinating care for the patient with other specialties and agencies. When this author asks the physicians/QHPs why they are not providing and reporting principal care management, they usually respond in one of two ways: (1) they say that the work they perform does not qualify for chronic care management, or (2) they say that they have never heard of principal care management codes.
It is true that few wound/ulcer management physicians/QHPs direct chronic care management or complex chronic care management, but this author believes that many of them are already providing principal care management, but do not know that codes were created for this service. To fill this knowledge gap, let us review the history of the Care Management Services and their affiliated codes. NOTE: Just like any new service or procedure, the Care Management Services codes have been refined multiple times since their inception.
The first Care Management Services codes (99487, 99488, 99489) were released 10 years ago in 2013 and were called Complex Chronic Care Coordination Services. These codes allowed for clinical staff reporting of care management services directed by physicians/QHPs and provided for at least 60 minutes per calendar year (Table). Wound/ulcer management physicians/QHPs may not have qualified to report these codes because the codes were primarily for clinical staff directed by a physician/QHP who was required to manage and/or coordinate all needed services for all medical conditions, psychosocial needs, and activities of daily living, and/or they pertained to patients who had one or more chronic continuous or episodic health conditions that were expected to last at least 12 months. NOTE: If a physician/QHP performed the clinical staff activities, that time was counted toward the required clinical staff time needed to meet the code description.
In 2015, the Current Procedural Terminology (CPT)*Codebook section title was changed to Care Management Services, which better describes the services provided by the clinical staff, physicians, and QHPs. In addition, new subsections-along with their own headings, guidelines, and codes-were added to the codebook. The first new subsection was called Chronic Care Management Services and its new code 99490 allowed reporting of services provided for at least 20 minutes per calendar month. The Complex Chronic Care Coordination Services section was renamed Complex Chronic Care Management Services, one code description was revised (99487), and one code (99488) was deleted because care management no longer required face-to-face visits (Table 1). These codes still required the physician/QHP to provide or oversee the management and/or coordination of services needed for all medical conditions, psychosocial needs, and activities of daily living, and again, if a physician/QHP performed the clinical staff activities, that time was counted toward the required clinical staff time needed to meet the code description.
Because a code did not exist for physicians/QHPs to report chronic care management that they personally provided, in 2019 code 99491 was created (Table). NOTE: Chronic care management service may only be reported by one physician/QHP at a given time within the calendar month and may not be reported with code 99490.
Then in 2022, major revisions were made to the Care Management Services section and subsections of the CPT Codebook. The introduction to Care Management Services was revised to emphasize that physicians/QHPs can personally provide care management services. Because a plan of care is an essential component of all care management services, the 2022 Codebook described the elements that are typically included in a care management services plan of care. In addition, the Chronic Care Management Services base codes (99490 and 99491) were revised to align with the new Chronic Care Management Services add-on codes that were created for each additional 20 minutes of clinical staff time (99439) and for each additional 30 minutes of services personally provided by a physicians/QHPs (99437).
Finally, and most important to wound/ulcer management physicians/QHPs, a third subsection was added to the Care Management Services section of the CPT Codebook: Principal Care Management Services. Four new codes were created to report services that focus on the medical and/or psychological needs of a patient with a single, complex chronic condition expected to last at least 3 months (Table). The service includes establishing, implementing, revising, or monitoring a care plan specific to that single disease. Once physicians/QHPs review these new codes, they may realize that they are already providing principal care management services for some of their patients, such as those with peripheral artery disease. In those cases, wound/ulcer management physicians/QHPs should formalize their processes and workflows by reviewing the 2023 CPT Codebook (pay attention to the excellent table that displays the staff type, time, and maximum reportable units per month) and implementing all of the coding requirements (including the care plan requirements) into their care management services. If physicians/QHPs perform principal care management services, they should receive the appropriate revenue.
* Current Procedural Terminology (CPT)(R) is a registered trademark of the American Medical Association. Copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. [Context Link]