Chronic Care Management Services

Policy No: 122
Originally Created: 03/01/2016
Section: Administrative
Last Reviewed: 06/01/2021
Last Revised: 06/01/2021
Approved: 06/10/2021
Effective: 07/01/2021

This policy applies to all contracted physicians, other health care professionals, hospitals, and other facilities.

Definitions

Chronic Care Management (CCM)
Services that are non-face-to-face care management/coordination services to members that have multiple (two or more) chronic conditions, expected to last at least 12 months, or until the death of the patient.

Clinical Staff
A person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individual report that professional service.

Incident To
Services that are furnished incident to physician professional services in the physician's office (i.e. separate office suite or within an institution) or in a member's home.

Policy statement

Note: This policy has been revised and renamed. The revised policy will be effective 1/1/2022. To view the revised policy, click here

When medical necessity criteria is met, our health plan reimburses for chronic care management services.

CPT Codes

The CPT codes used to report CCM services are:

  • 99490 for the first 20-minutes of non-complex CCM provided by clinical staff to coordinate care across providers and support patient accountability.
    • Reported once per calendar month
    • 99439 (effective 1/1/2021) is reported for each additional 20 minutes of non-complex CCM (replaced G2058).
      • Cannot be billed more than twice per calendar month.
  • 99487 for the first 60-minutes of complex CCM provided by clinical staff to revise or establish comprehensive care plan that involves moderate- to high-complexity medical decision making.
    • Reported once per calendar month
  • 99489 is reported for each additional 30 minutes of complex CCM services
    • Reported once per calendar month
    • Cannot be billed with CPT code 99490
  • 99491 for at least 30 minutes of CCM services provided personally by a physician or other qualified health care professional.
  • Reported once per calendar month

Chronic Care Management care planning may be face-to-face and/or non-face-to-face, but the time spent doing the CCM care planning must not already be reflected in the CCM initiating visit itself if the physician reports an Evaluation and management service on the same day.

Additional requirements include, but are not limited to, the following:

  • Only one clinical staff can bill and receive reimbursement for CCM services once per calendar month. Specifically, the member would be classified as eligible to receive CCM services for either complex (99487/99489), non-complex (99490/99439), or those provided personally by a physician or other qualified health care professional (99491).

Add-On Code

  • G0506 Comprehensive assessment of and care planning for patients requiring CCM services (list separately in addition to primary monthly care management service)

    • This is an add-on code to be used with another evaluation and management (E&M) service (the chronic care management initiating Annual Wellness Visit/Initial Preventive Physical Examination AWV/IPPE or qualifying face-to-face E&M visit).
    • It cannot be an add-on code for the behavioral health initiative (BHI) initiating visit or BHI services.
    • It is meant to account specifically for additional work of the billing provider in:
      • Personally, performing a face-to-face assessment
      • Personally, performing CCM care planning
    • Only billable one time, at the onset of CCM services

Required elements for billing 99490/99439:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the member at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored
  • 99490 is reported for the first 20 minutes of clinical staff time, directed by a physician or other qualified health care professional for chronic care management services and is allowed once per calendar month.
    • Do not report if less than 20 minutes
  • 99439 is to be listed separately in addition to the primary procedure code (99490) and is to only be billed for each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional

    • This code cannot be reported more than twice per calendar month.

Required elements for billing 99487 and 99489:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored
  • Medical decision making is of moderate or high complexity
  • 99487 is reported for the first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, for complex chronic care management services
    • Do not report if less than 60 minutes
  • 99489 is to be listed separately in addition to the primary procedure code (99487) and is to be billed for each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional

    • Do not report if less than 30 minutes

Required elements for billing 99491:

  • Chronic care management 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, 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

CCM Services for Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs).

  • G0511, rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month.
  • G0512, Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month.

Principal Care Management (PCM)

Effective 01/01/2020 CMS created two new G-codes that can be billed to describe care management services for ONE serious chronic condition. A qualifying condition is expected to last between 3 months and 1 year, or until the death of the patient, may have led to a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

  • G2064 - Comprehensive care management services for a single high-risk disease, e.g., principal care management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.
  • G2065 - Comprehensive care management for a single high-risk disease services, e.g. principal care management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

Qualified clinical staff include:

  • Physicians
  • Certified Nurse Midwives (CNM)
  • Clinical Nurse Specialists (CNS)
  • Nurse Practitioners (NP)
  • Physician Assistants (PA)
  • Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs)
  • Hospitals (including critical access hospitals)

"Incident to" billing may be utilized for CCM services. Clinical staff are to follow the “incident to” billing requirements as defined by CMS.

Proper modifier 25 coding and billing guidelines, in addition to meeting medical necessity criteria, must be followed if billing for both E&M and CCM services on the same day for the same member by the same clinical staff. If coding and billing requirements for modifier 25 are not met, clinical staff time for CCM services cannot be counted on the same day as the E&M service.

Clinical staff are to follow the CMS CCM Scope of Service Elements and Billing Requirements. Information on these requirements are located on the CMS webpage Connected Care: The Chronic Care Management Resource under Health Care Professional Resources.

Additional Billing Requirements

CCM services that cannot be billed during the same service period, except as previously noted by CMS, are:

  • 90951-90970 (End Stage Renal Disease services)
  • In the postoperative period of a reported surgery
  • 93792-93793 (Anticoagulant training/management)
  • 98960-98962 (Education and training)
  • 98966-98968 (Telephone assessment and management services
  • 99071, 99078 (Education supplies/training)
  • 99080 (Preparation of special reports)
  • 99091 (Remote patient monitoring)
  • 99358-99359 (Prolonged services, without direct patient contact)
  • 99366-99368 (Medical team conferences)
  • 99421-99423 (Online digital evaluation and management service)
  • 99441-99443 (Telephone services)

CCM services that cannot be billed during the same service period with 99439 and 99490, except as previously noted by CMS, are:

  • 98970-98972 (Online digital assessment and management)
  • 99605-99607 (Medication therapy services)

CCM services that cannot be billed during the same service period with 99487 and 99489, except as previously noted by CMS, are:

  • 99339-99340 (Care plan oversight services)
  • 99374-99380 (Supervision of patient care, without direct patient contact; home health, hospice, nursing facility)
  • 99605-99607 (Medication therapy management services)

Do not report 99491 with 99495-99496 (transitional care management services)

For psychiatric care management services, see 99492-99494

CCM services will not be reimbursed:

  • For individuals located outside the United States

Telehealth/Telemedicine Services

CCM Services may be billed under the Physician Fee Schedule (PFS) or Outpatient Prospective Payment System (OPPS).

Facility Billing Rules

  • Refer to the CMS Connected Care: The Chronic Care Management Resource webpage on CCM requirements for scope of service elements furnished to hospital outpatients under the OPPS
  • The time spent providing CCM services to the member while he/she is not inpatient can be counted towards the minimum minutes of service time that is required to bill for that month
  • Hospitals are able to bill CCM services only when furnished to a member who has been either admitted to the hospital as an inpatient or has been registered outpatient of the hospital within the last 12 months and for whom the hospital furnished therapeutic services
  • If the place of service for CCM becomes the hospital outpatient department, it is assumed that the member has established a relationship with the hospital for CCM services
  • A provider-based outpatient department of a hospital is part of the hospital and therefore may bill for CCM services furnished to eligible members, provided it meets all applicable requirements. A hospital-owned practice that is not provider-based to a hospital is not part of the hospital and, therefore, not eligible to bill for services under the OPPS; however, the clinical staff practicing in the hospital-owned practice may bill under the CMS Physician Fee Schedule for CCM services furnished to eligible members, provided all billing requirements are met
  • When a clinical staff furnishes CCM services in a hospital outpatient department to an eligible member, the clinical staff may bill CCM services using place of service 22 (outpatient hospital). Reimbursement to the clinical staff will be made at the CMS Physician Fee Schedule facility rate
  • As only one clinical staff is allowed to bill for CCM services during a calendar month service period, accordingly, only one hospital is allowed to bill and be paid for CCM services during a calendar month service period

Claims received for Chronic Care Management Services are processed based on the date the claim is received.

References

Centers for Medicare & Medicaid Services (CMS). Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2020. CMS-1715-F, p. 120-132

Centers for Medicare & Medicaid Services (CMS). Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019. CMS-1693-F, p. 126 and 232–234

Centers for Medicare & Medicaid Services (CMS). Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018. CMS-1676-F, p. 120 and 515-550

Centers for Medicare & Medicaid Services (CMS). Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017. CMS-1654-F, p. 215-219, and 278-311

Centers for Medicare & Medicaid Services (CMS). Chronic Care Management Services Changes for 2017

Centers for Medicare & Medicaid Services (CMS). Outpatient Prospective Payment System (OPPS) 2017 Final Rule, Section D

Current Procedural Terminology (CPT®) Manual, AMA, 2017. Accessed via Optum360 EncoderPro.com Professional

Centers for Medicare & Medicaid Services (CMS). Chronic Care Management Services Webinar. Delivering Coordinated Care through Chronic Care Management Services

Centers for Medicare & Medicaid Services (CMS). Outpatient Prospective Payment System (OPPS) 2016 Final Rule, Section C

Centers for Medicare & Medicaid Services (CMS). INC 909188 - Chronic Care Management Services, May 2015

Centers for Medicare & Medicaid Services (CMS). Frequently Asked Questions about Billing Medicare for Chronic Care Management Services

Centers for Medicare & Medicaid Services (CMS). CMS MLN Matters # SE0441 - "Incident to" Services, April 2013

Centers for Medicare & Medicaid Services (CMS). Telehealth/Telemedicine website

Cross References

Virtual Care

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.