Do the billing and claim requirements from the Centers for Medicare and Medicaid Services (CMS) confuse or scare you?
We’ve heard these concerns from many practices we’ve worked with over the years.
The good news is that while at first glance these requirements can be intimidating, they are relatively straightforward.
We have helped guide countless practices through CMS rules and regulations, including helping them understand the billing and claims submission process.
These practices who at once were concerned about starting a care coordination program, went on to run successful programs offering new substantial revenue streams for themselves while providing better health outcomes for their patients.
Because so many clients have seen success after overcoming these small, but seemingly large hurdles, we have put together a useful guide based on that experience that walks you through CMS billing and claims submission requirements.
Below we break down everything you need to know about how to bill and submit claims to CMS for the various care coordination and wellness programs.
What Do You Need to Bill and Submit Claims through CMS?
CPT Codes for each program you’re managing for the patient
ICD-10 codes tied to each of the conditions you’re managing within that program
Date of service
Place of service
Not needed, but helpful if you’re ever audited:
Care Manager assigned to the patient
These are all relatively easy items to find when managing a care coordination program. To better understand why you’ll need each of these items, you’ll first need to understand what they are.
What Are CPT Codes?
Common Procedural Technology (CPT) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical, and diagnostic services.
Insurers use these codes to determine and verify the amount of financial reimbursement that a practitioner will receive for that service.
A CPT code is a five-digit numeric code with no decimal marks (although some have four numbers and one letter).
Take Chronic Care Management for example:
CMS has 6 different CPT codes to allow providers to reimburse for non-face-to-face care coordination services that are dependent on the time logged, type of practice, and/or level of care. The current national average reimbursement for CCM CPT code 99490 is around $42.
What Are ICD-10 Codes?
ICD-10 codes identify medical diagnoses, informing insurance companies what care you provided and why.
For other CMS programs like Remote Patient Monitoring (RPM), Annual Wellness Visits (AWV), Behavioral Health Integration (BHI, and Transitional Care Management (TCM), you must attach at least one ICD-10 code.
There are over 69,000 ICD-10 codes (and the list continues to grow) that a practice can use to identify various diagnoses.
While your EHR may provide certain capabilities to help in this regard, many practices find them to be clunky, unintuitive, and sometimes prone to errors in assigning codes properly.
For CPT codes, good care management software will automatically assign the proper CPT code depending on the type of treatment and amount of time logged.
For ICD-10 codes, look for software that includes easily searchable lists that are tailored to whichever CMS program you’re managing.
The best software solutions will give you the most commonly used ICD-10 codes for chronic conditions you'll be managing. (e.g., ThoroughCare has all of the ICD-10 codes that we know have been accepted by CMS in the past.)
We know shopping for care management software can be a burden. Providers want to know what the benefits are, what features to look for, and how to choose the right options.