The Centers for Medicare & Medicaid Services (CMS) recognizes that CCM services are critical components of primary care that promote better health and reduce overall health care costs. In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions. The CCM service is extensive, including structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the practice. 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.
Practitioner and Patient’s Eligibility
Physicians and non-physician practitioners like: certified nurse-midwives; clinical nurse specialists; nurse practitioners; and physician assistants, may bill CCM services. These services may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM. Note that only one practitioner may be paid for CCM services for a given calendar month. The billing practitioner cannot report both complex and non-complex CCM for a given patient for a given calendar month.
Patients with multiple 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. Some of the examples of chronic conditions include Alzheimer’s disease and related dementia; asthma; atrial fibrillation; autism spectrum disorders; cancer; cardiovascular disease; chronic obstructive pulmonary disease; depression; diabetes; hypertension; infectious diseases such as HIV/AIDS; and arthritis (osteoarthritis and rheumatoid).
- CPT Code 99490 (Non-Complex CCM): 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.
- CPT Code 99491 (Non-Complex CCM): Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of a physician or other qualified health care professional time, per calendar month.
- The required elements for CPT 99490 and 99491 code include 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; and Comprehensive care plan established, implemented, revised, or monitored.
- CPT Code 99487 (Complex CCM): 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, moderate or high complexity medical decision making, with the establishment or substantial revision of a comprehensive care plan. Required conditions include: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; and chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.
- 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)
Billing Guidelines for Medicare Chronic Care Management
- practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical record. 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.
- For new patients or patients not seen within 1 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 another face-to-face visit 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. is reportable once per CCM billing practitioner, in conjunction with CCM initiation.
- 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.
- Non-Complex CCM and complex CCM services share a common set of service elements. 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.
- CPT code 99491 includes 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.
Please note that billing information shared in this article applies only to the Medicare Fee-For-Service (FFS) Program also known as Original Medicare. We tried to cover every billing aspect for complex and non-complex chronic care management in this article. If you need any billing or coding assistance for Medicare services, contact Medisys Data Solutions. Our team is well versed with Medicare coding and billing guidelines which ensure accurate reimbursements. To know more about our Medicare billing and coding services, contact us at email@example.com/ 302-261-9187