Chronic Care Management Services

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The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals.

In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions.

This fact sheet provides background on payable CCM service codes, identifies eligible practitioners and patients, and details the Medicare PFS billing requirements. Beginning January 1, 2017, the CCM codes are:

CCM

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

Complex CCM

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.
  • CCM (sometimes referred to as “non-complex” CCM) and complex CCM services share a common set of service elements (summarized in Table 1). They differ in the amount of clinical staff service time provided; the involvement and work of the billing practitioner; and the extent of care planning performed.

Practitioner Eligibility

Physicians and the following non-physician practitioners may bill CCM services:

  • Certified Nurse Midwives
  • Clinical Nurse Specialists
  • Nurse Practitioners
  • Physician Assistants

NOTE: 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.

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).

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 in order to bill CCM services. Non-clinical staff time cannot be counted toward the threshold.

Supervision

The CCM codes (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required.

Patient Eligibility

  • Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline are eligible for CCM services.
  • Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications, or repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language.
  • There is a need to reduce geographic and racial/ethnic disparities in health through the provision of CCM services. Table 2 provides a number of resources for identifying and engaging subpopulations to help reduce these disparities.
  • The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex CCM during a given service period, not both.

Examples of chronic conditions include, but are not limited to, the following:

  • Alzheimer’s disease and related dementia
  • Cardiovascular Disease
  • Arthritis (osteoarthritis and rheumatoid)
  • Chronic Obstructive Pulmonary Disease
  • Asthma
  • Depression
  • Atrial fibrillation
  • Diabetes
  • Autism spectrum disorders
  • Hypertension
  • Cancer
  • Infectious diseases such as HIV/AIDS

Initiating Visit

  • For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires 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.

Patient Consent

Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical record, and includes informing them about:

  • The availability of CCM services and applicable cost-sharing
  • That only one practitioner can furnish and be paid for CCM services during a calendar month
  • The right to stop CCM services at any time (effective at the end of the calendar month)

Informed patient consent need only be obtained once prior to furnishing CCM, or if the patient chooses to change the practitioner who will furnish and bill CCM.

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