Medical Billing Services

Billing Guidelines for Chronic Care Management (CCM)

Chronic Care Management (CCM) services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. The Centers for Medicare & Medicaid Services (CMS) recognizes that CCM is a critical component of primary care that promotes better health and reduces overall health care costs.

Practitioner Eligibility

Physicians and these non-physician practitioners may bill CCM services – Certified Nurse-Midwives; Clinical Nurse Specialists; Nurse Practitioners; and Physician Assistants. Only one practitioner may be paid for CCM services for a given calendar month. This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both).

CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM. The CCM service is not within the scope of practice of limited-license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.

CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner), subject to applicable state law, licensure, and scope of practice. The clinical staff is either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM.

CPT code 99491 includes the only time that is spent personally by the billing practitioner. Clinical staff time is not counted towards the required time threshold for reporting this code. CPT codes 99487, 99489, and 99490 – Time spent directly by the billing practitioner or clinical staff counts toward the threshold clinical staff time required to be spent during a given month.

Initiating Visit

For new patients or patients not seen within 1 year prior to the commencement of CCM, Medicare requires the initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visits with the billing practitioner). This initiating visit is not part of the CCM service and is separately billed.

Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]). G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.

Approaches to Help Your Practice Get Started

  • Identify Medicare Part B patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient.
  • Prioritize patients at the highest risk of hospitalization or have recently been/are regularly seen in the emergency room.
  • Start with patients that regularly call into the clinic to manage symptoms or with medical questions.
  • Identify patients that may be most likely to benefit from care management based on the number of specialists involved in their care or who have limited social or local family support.
  • Identify patients dually eligible for traditional Medicare and Medicaid (not managed Medicaid).
  • Identify volume needed to hire additional part-time or full-time staff and then prioritize eligible patients.

CCM Coding

The four CPT codes used to report CCM services are 99490, 99491, 99487, and 99489

CPT 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, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored
  • Assumes 15 minutes of work by the billing practitioner per month.

CPT 99491:

Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of the physician or other qualified health care professional time, per calendar month, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored

CPT 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 death 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

CPT 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 procedure). Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately. Report 99489 in conjunction with 99487. Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month.

Hopefully, these guidelines help you understand the basics of billing Chronic Care Management. As always, make sure to check with your local Medicare carrier and other insurance companies on their rules and policies on how to bill for CCM. In case of any issues billing for chronic care management, contact Medical Billers and Coders (MBC) at 888-357-3226/info@medicalbillersandcoders.com

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