Chronic care management
From complex versus non-complex care to documentation and billing codes, here's your complete guide.
Chronic care management (CCM) services are 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.
Medicare beneficiaries who qualify for CCM services benefit from additional support and resources that help them manage their chronic conditions effectively. More coordinated care leads to better health and decreased overall health care costs. As the health care system transitions from a fee-for-service model to value-based payment, billing CCM services makes it possible for you to be paid for the time and effort you and other care team members invest in caring for your patients who have chronic conditions.
CCM coding
The five CPT codes used to report CCM services are:
99490: Non-complex CCM is a 20-minute timed service to coordinate care across providers and support patient accountability.
99439*: Each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified health care professional
99491: CCM services provided personally by a physician or other qualified health care professional for at least 30 minutes.
99487: Complex CCM is a 60-minute timed service to substantially revise or establish comprehensive care plan with moderate- to high-complexity decision-making.
99489**: Each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualified health care professional
99437: Each additional 30 minutes of physician or qualified health care professional time spent providing non-complex CCM (billed with 99491)
*billed in conjunction with CPT code 99490
**report in conjunction with CPT code 99487; cannot be billed with CPT code 99490
Requirements and components for CCM and complex CCM
CCM services that must be documented in the electronic health record (EHR). Covered services include but are not limited to:
- Management of chronic conditions
- Management of referrals to other providers
- Management of prescriptions
- Ongoing review of patient status
Requirements:
- Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
- Patient consent (verbal or signed)
- Personalized care plan in a certified EHR and a copy provided to patient
- 24/7 patient access to a member of the care team for urgent needs
- Enhanced non-face-to-face communication between patient and care team
- Management of care transitions
- At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by physician or other qualified health care professional
- CCM services provided by a physician or other qualified health care professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management activities
Shares common required service elements with CCM but has different requirements for:
- Amount of clinical staff service time provided (at least 60 minutes)
- Complexity of medical decision making involved (moderate to high complexity)
Who can provide and bill CCM services?
Only one physician or other qualified health care professional who assumes the care management role for a beneficiary can bill for providing CCM services to that patient in a given calendar month. While services may be provided by a clinical staff person, the service must be billed under one of the following:
Physician
Clinical nurse specialist (CNS)
Nurse practitioner (NP)
Physician assistant (PA)
Certified nurse midwife
Non-physicians must legally be authorized and qualified to provide CCM in the state in which the services are furnished.
Step-by-step approach to adding CCM services to your practice
Chronic care management can help manage your patients’ chronic conditions more effectively, improve communication among other treating clinicians and help optimize revenue for your practice. Here’s how to 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.
Risk-stratify your patient panel using the AAFP risk-stratified care management rubric and algorithm. Prioritize patients at highest risk of hospitalization.
Identify patients most likely to benefit from care management based on the number of specialists involved in their care, or 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.
More CCM resources from the AAFP
The AAFP’s position on CCM services
The AAFP’s advocacy efforts helped pave the way for Medicare payment for CCM services, giving family physicians an opportunity to be paid for the many services they provide outside traditional face-to-face office visits. The AAFP believes that family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive and connected health care.