Are you being reimbursed for the work of your navigator staff in their management of the complex oncology patient?

Posted by Cam McClellan Teems

February 17, 2015 at 10:29 AM


Here is a new option in 2015....

The Complex Care Management CPT code updates for 2015 fit directly in the cross-hairs of navigation work. Karna Morrow of Coding Strategies based outside of Atlanta, Ga, says the code update in 2015 came from "an effort to reimburse the primary care physician who is managing the chronic and complex patient in their practice in off-hours when they are not seeing patients."  She says there is definitely applicability to oncology care coordination and navigation for the patient with cancer plus a co-morbid condition like diabetes, hypertension or COPD, etc.  

The CPT codes and their technical components would be used by the oncology program for patients under complex chronic care management by the program staff. In the rule published on July 3, 2014, CMS proposed a reimbursement of $42 for the service -- covered under codes 99487-99489.  This is per :60 minutes per month.

Let's do the possible math:  100 patients x $42 (facility fee % of the total $42) x let's say 18 months of complex chronic care = @$36,000* per applicable patient

*assumes $20 of the $42 is the facility portion


Here is the definition:

Complex Chronic Care Management Services

Codes 99487 and 99489 are used to report Complex Chronic Care Management Services. The code descriptions for these codes have been changed and now read as follows:

99487 - Complex chronic care management services, with the following required elements:

  • multiple (two or more) chronic conditions expected to last at least 12 months, or until the dealth 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 - 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 work)

Technical component of 99487 or 99489 would include its employed nurses overseeing complex chronic care for oncology patients.  Note:  this cannot be also billed by the physician.  One entity/facility bills this per month and one entity alone.


Topics: reimbursement, billing, Navigation & Care Coordination

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