Chronic Care Management

Chronic Care Management (CCM) is a critical primary care service that contributes to better patient health and care. These physicians and Non-physicians Practitioners (NPP) may bill CCM services:

• Certified Nurse Midwives (CNM)

• Clinical Nurse Specialists (CNS)

• Nurse Practitioner (NP)

• Physician Assistant (PA)

CPT Code 99491 - Time only the billing practitioner spends. Clinical staff time doesn’t count toward the required reporting time threshold code.

CPT Codes 99487, 99489, and 99490 - Time spend directly by clinical staff. Time spend by the billing practitioner may also count toward the time threshold if not used to report 99491.

For CCM services the billing practitioner doesn’t personally furnish the services, the clinical staff furnish them under direction of the billing practitioner on an incident to basis (as an integral part of services furnished by the billing practitioner), subject to applicable state law, licensure, and scope of practice. Clinical staff are employees or working under contract with the billing practitioner. Payment is made directly to the billing practitioner for CCM services.

Supervision

• CCM codes are assigned describing staff activities (CPT 99487, 99489, and 99490) as general supervision.

• General supervision means when the billing practitioner doesn’t personally furnish the service, it’s done under their overall direction and control.

• There is no requirement for the physician’s physical presence while service is furnished.

Patient Eligibility

• Eligible CCM patients will have multiple (2 or more) chronic conditions expected to last at least 12 months or until the patient’s death and/or that place them at significant risk of death, acute exacerbation and/or decompensation, or functional decline.

• These services aren’t typically face-to-face and allow eligible practitioners to bill at least 20 minutes or more of care coordination services per month.

• Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (like number of illnesses, number of medications, repeat admissions, or emergent department visits) or the typical patient profile in the CPT prefatory language.

Examples of chronic conditions include, but aren’t limited to:

• Alzheimer’s disease and related dementia

• Arthritis (osteoarthritis and rheumatoid)

• Asthma

• Atrial Fibrillation

• Autism spectrum disorders

• Cancer

• Cardiovascular disease

• Chronic Obstructive Pulmonary Disease (COPD)

• Depression

• Diabetes

• Hypertension

• Infectious diseases like HIV and AIDS

Initiating Visit

• Before CCM services can start, you are required to have an initiating visit for new patients or patients who the billing practitioner hasn’t seen within 1 year.

• Initiating visit can occur during comprehensive face-to-face E&M visit, annual wellness visit (AWV), or initial preventative physical exam (IPPE).

• If practitioner doesn’t discuss CCM during an E&M visit, AWV, or IPPE, it can’t count as the initiating visit.

• Face-to-face initiating visit isn’t part of CCM and can be separately billed.

Practitioners who personally furnish extensive assessment and care planning outside the usual effort described by the initiating visit and CCM codes may also bill:

HCPCS code G0506 - Comprehensive assessment of and care planning by the physician or other qualified heal care practitioner for patients requiring CCM services (billed separately from monthly care management services) (Add-on code, list separately in addition to primary service)

Billing practitioners can bill G0506 only once, as part of initiating visit.

Patient has the right to stop CCM services at any time (effective the end of the calendar month).

Comprehensive Care Plan

A comprehensive care plan for all health issues typically includes, but isn’t limited to:

• Problem list

• Expected outcome and prognosis

• Measurable treatment goals

• Cognitive and functional assessment

• Symptom management

• Planned interventions

• Medication management

• Environmental evaluation

• Caregiver assessment

• Interaction and coordination with outside resources, practitioners, and providers

• Requirements for periodic review

• When applicable, revision of the care plan

Concurrent Billing

You can’t report complex CCM and non-complex CCM for the same patient in a calendar month. Don’t report 99491 in the same calendar month as 99487, 99489, or 99490.

You can’t bill CCM during the same service period by the same practitioner as HCPCS codes G0181 or G0182 (home health care supervision, hospice care supervision) or CPT codes 90951-90970 (certain ESRD services)

You can report CCM codes 99487, 99489, 99490 and 99491 by the same practitioner for services furnished during the 30 day TCM service period (CPT 99495, 99496)

You can’t report complex CCM and prolonged E&M services in the same calendar month.

You can’t count time toward the CCM service code for any other billed code.