Chronic care management (CCM) services help improve the quality of care and health outcomes for patients with chronic conditions while reducing overall costs. But navigating the reimbursement process for CCM can often be complex and confusing. To simplify things, we are answering some of the most frequently asked questions about CCM reimbursement.
What is Chronic Care Management?
According to The Centers for Medicare & Medicaid Services (CMS), CCM services help improve the quality of care for Medicare beneficiaries with two or more chronic conditions. CCM involves comprehensive care coordination provided outside of face-to-face visits to help patients manage their chronic conditions more effectively.
Who is eligible for CCM services?
Medicare beneficiaries who have two or more chronic conditions expected to last at least 12 months are eligible for CCM services. These chronic conditions must place the patient at significant risk.
What services are included in CCM?
CCM includes non-face-to-face care services such as comprehensive care planning, medication management, coordination of care transitions, and communication with other healthcare professionals involved in the patient’s care.
How is CCM reimbursed, and what are the CCM CPT codes?
Under the Physician Fee Schedule, Medicare will reimburse for CCM services using specific CPT billing codes, depending upon the complexity of the patient’s needs and time spent on care coordination activities.
- CPT Code 99490 ($62): CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month
- CPT Code 99439 ($47): Add-on code for CPT code 99490; each additional 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month
- CPT Code 99491 ($83): CCM services provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month
- CPT Code 99437 ($59): Add-on code for CPT code 99491; each additional 30 minutes by a physician or other qualified health care professional, per calendar month
- CPT Code 99487 ($132): Complex CCM, first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
- CPT Code 99489 ($71): Add-on code for CPT code 99487; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
Please note: Reimbursement amounts represent Medicare’s national non-facility averages. Actual reimbursement amounts may vary by geography and payer.
Are there specific documentation requirements for CCM?
Yes, providers must document the time spent on care coordination activities, as well as the patient’s consent to participate in CCM services and the development of a comprehensive care plan. Documentation should be thorough, accurate, and compliant with Medicare guidelines.
How often can CCM services be provided?
CCM services can be provided to eligible patients once every calendar month. Providers should reassess the patient’s eligibility and need for CCM services regularly to ensure appropriate and timely care coordination.
Do the billing practitioners need to ever see their CCM patients face-to-face?
Yes. For new patients or patients not seen by the billing practitioner within a year prior to the commencement of CCM services, CCM must be initiated by the billing practitioner during a “comprehensive” evaluation and management visit (E/M visit), annual wellness visit (AWV) or initial preventive physical exam (IPPE).
Does informed consent for CCM have to be obtained at the time of the initial visit?
The initiating visit for CCM and informed consent are two separate requirements for CCM services. The billing practitioner must discuss CCM with the patient at the initiating visit. While the initiating visit presents an opportunity to obtain the required informed consent, informed consent does not have to be obtained during the initiating visit.
What elements are required to be included in the CCM care plan?
Below are the typical care plan elements per the Centers for Medicare and Medicaid Services (CMS). Note that these are “typical” care plan elements, and do not comprise a set of strict requirements that must be included for billing CCM. The comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:
- Problem list
- Expected outcome and prognosis
- Measurable treatment goals
- Cognitive and functional assessment
- Symptom management
- Planned interventions
- Medical management
- Environmental evaluation
- Caregiver assessment
- Interaction and coordination with outside resources and practitioners and providers
Can CCM be billed in conjunction with RPM?
Yes, a provider can bill for both CCM and RPM services. CMS recognizes that CCM services are complimentary to RPM and other care management services. However, time spent by providers in furnishing these services must be counted separately. Billing CCM CPT Code 99490 and RPM CPT code 99457 together requires a provider to deliver at least 40 minutes of services: 20 minutes of CCM and 20 minutes of RPM.
Can CCM Services be provided by Non-Physician Practitioners?
Yes, CCM services can be provided by non-physician practitioners such as nurse practitioners, physician assistants, and clinical nurse specialists, under the supervision of a physician.
Certain CCM codes describe time spent per calendar month by “clinical staff.” What is the definition of “clinical staff” for CCM reimbursement?
Per the American Academy of Family Physicians (AAFP), a clinical staff member is defined as “a person who works under the supervision of a physician or other qualified healthcare professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service but does not individually report that professional service.”
Can CCM services be completely delegated to clinical staff?
No. The billing practitioner must retain a certain level of involvement in CCM. The CCM service codes for reporting clinical staff time are valued to include a certain amount of ongoing practitioner work, including oversight, management, collaboration, and reassessment by the billing practitioner consistent with the included service elements. Additionally, complex CCM includes moderate to high complexity medical decision-making by the billing practitioner, an activity that cannot be subcontracted to any other individual. The CCM service codes for reporting services furnished directly by the billing practitioner (CPT code 99491, 99437) cannot be delegated or subcontracted to auxiliary personnel.
Can the clinical staff portion of CCM be performed by external third-party companies?
Yes. A billing practitioner may arrange to have the clinical staff portion of CCM services provided by clinical staff external to the practice (such as by a case management company) if all the “incident to” and other rules for billing CCM are met. However, if there is little oversight by the billing practitioner or a lack of clinical integration between a third party providing CCM and the billing practitioner, CCM cannot be furnished and therefore the practitioner should not bill for CCM.
Where can I go for additional information about CCM?
For more information regarding CCM reimbursement for your healthcare organization, schedule a consultation with one of our specialists.
This content is for informational purposes only and should not be taken as legal advice.