Chronic Care Management Billing Rules

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Billing the proper medical codes is a crucial part of providing Chronic Care Management (CCM) services for Medicare patients. CCM is a service for Medicare patients with at least two chronic health conditions that increase their risk of functional decline or death. 

Chronic Care Management CPT codes reimburse medical practices for the chronic care services they provide, and it’s important to use the correct CPT codes for different CCM services. By understanding the guidelines and requirements for each chronic care medical code, you can ensure you receive the correct reimbursement for your services. 

It’s important to know when to use certain initial codes, add-on codes and complex codes. Understanding Chronic Care Management billing rules helps your practice receive the correct reimbursement for delivered services. Learn more about CPT billing rules and requirements for eligible services and equipment. 

CCM Codes: 99490 and 99491

Chronic conditions affect approximately 117 million Americans, so the Centers for Medicare and Medicaid Services (CMS) took action in 2015 to promote prevention and health maintenance for chronically ill patients. CMS now reimburses providers who implement the program, Non-Complex Chronic Care Management. 

The CCM program provides non-face-to-face services for Medicare patients who have two or more chronic health conditions, and its purpose is to prevent conditions and symptoms from worsening. It helps individuals avoid unnecessary hospital visits, saving them money annually. Providers bill services within the CCM program as code CPT 99490. 

CPT code 99490 differs from CPT 99491. While CPT 99490 reimburses providers for non-face-to-face services by clinical staff, CPT 99491 reimburses providers when the billing practitioner directly manages patient care. CPT 99490 can be billed under general supervision when other clinical staff under a physician’s direction carry out care coordination tasks.

CPT 99490 and CPT 99491 also differ in the amount of time they cover. CPT 99490 covers 20 minutes of services, and CPT 99491 covers 30 minutes.

CCM Add-On Codes

CCM CPT 99439 is an add-on code for CPT 99490. It can be billed monthly for each additional 20 minutes of care provided to the CCM patient. Like 99490, it can be performed by clinical staff under general supervision from a physician.  

CPT 99437 is an add-on code for CPT 99491, and it covers each additional half-hour in CCM services a physician provides in one month. Since it’s an add-on code, providers should only bill it for the time they spend with eligible patients beyond their initial half-hour billed under code 99491.

RHC and FQHC CCM

The Health Care Common Procedure Coding System (HCPCS) G0511 code applies to federally qualified health centers (FQHC) and rural health clinics (RHC). It covers 20 minutes or more of behavioral health integration services or CCM services that clinical staff or a practitioner provides in one month.

RHC and FQHC health care providers can bill CPT G0511 alone or with other provided services. An RHC or FQHC must meet the requirements for CPT 99487, CPT 99490 or CPT 99484 to bill CPT G0511. When your FQHC or RHC practice bills code G0511 for reimbursement, you can increase your practice’s revenue significantly as the reimbursement rate is higher than for 99490. 

Complex CCM Codes 

The Chronic Care Management benefit expanded in 2017 and introduced complex CCM codes. Complex codes apply to patients who need more time with clinical staff or a physician than primary CCM codes cover. They cover additional time for patients when physicians need to help them make moderately or highly complex medical decisions.

To bill CCM 99487, a provider’s patient must meet the following requirements: 

  • At least two chronic medical conditions that increase the risk of functional decline, acute decompensation or death
  • Chronic conditions that their care provider expects them to have for at least one year or for the remainder of their life
  • A chronic care plan or a substantial revision to an existing chronic care plan
  • Highly or moderately complex medical decisions to make
  • First 60 minutes spent with a qualified health care provider per month

CCM Complex Add-On Code

CPT 99489 is a complex Chronic Care Management add-on code that care providers can report in conjunction with code 99487. It should not be reported independently. CPT 99487 covers one hour a patient spends with their care provider, and CPT 99489 covers each additional half-hour of services they require in one month. 

Codes for Principal Care Management

Codes for Principal Care Management (PCM) apply to patients with one or more chronic health conditions, but the care is focused on one specific, high-risk condition. Contrasting from CCM, the condition can be expected to last as little as three months. Care can include services such as making a care plan, medication adjustments and patient follow-ups. 

CMS finalized four new PCM codes in 2022. The final rule of Medicare’s physician fee schedule added the initial primary codes, CPT 99424 and CPT 99426, to replace codes G2064 and G2065.

CPT 99424 covers the first half-hour a physician personally provides services for a single chronic condition in one month. Practices can report this code when a patient meets the following requirements:

  • They have a chronic condition their care provider expects them to have for at least three months.
  • Their condition requires the revision, monitoring or development of a disease-specific health care plan.
  • They need frequent medication regimen adjustments or their condition requires complex management because of comorbidities.
  • Relevant practitioners engage in ongoing care coordination and communication to treat their condition.

CPT 99426 covers the first half-hour of care clinical staff provides for a high-risk health condition with these factors:

  • Initial monitoring or assessment using the applicable rating scales
  • Mental health care planning for psychiatric or behavioral health conditions, including health care plan revisions
  • Coordinating and facilitating psychotherapy treatment, pharmacotherapy, psychiatric consultation or counseling
  • Continuing care from a designated care team member

CPT 99424 and CPT 99426 may seem similar in what they cover. However, they have a slight difference. CPT 99424 covers care that a health care professional personally provides. CPT 99426 covers care that a clinical staff member provides under a physician’s direction. 

Principal Care Management Add-On Codes

In 2022, the Medicare physician fee schedule also finalized new add-on codes, which are CPT 99425 and CPT 99427. CPT 99425 covers each additional 30 minutes a health care professional personally provides PCM services for a patient in one month. To bill this code, you must list it separately in addition to a primary procedure code. 

CPT 99427 covers each additional 30 minutes of PCM services provided by clinical staff under supervision from a physician or another health care professional. It must also be listed separately in addition to a primary procedure code. When you report CPT 99425 or CPT 99427, you must report it in conjunction with its initial primary code. This means that you must report CPT 99425 in conjunction with CPT 99424, and CPT 99427 in conjunction with CPT 99426.  

CCM Care Planning

If a patient is new or if the billing practitioner has not seen the patient within one year, an initiating visit is required. The initiating visit can occur during any of the following services:

  • Annual Wellness Visit
  • Face-to-face evaluation and management visit
  • Initial preventive physical exam

In order for any of the listed services to count as an initiating visit, the practitioner must discuss CCM during the visit. A billing practitioner should bill a face-to-face initiating visit separately if it is not part of CCM.

Practitioners sometimes need to personally perform care planning and extensive assessment outside of the regular effort defined by CCM codes and initiating visits. In these cases, billing practitioners can also bill HCPCS code G0506 as an add-on code.

Practitioners may only bill HCPCS code G0506 once as part of a patient’s initiating visit, and they must list it separately from monthly CCM services. If you bill HCPCS code G0506, you must report it separately from the following care management codes:

  • 99490
  • 99491
  • 99487
  • 99489

Behavioral Health Code CPT 99484

CPT 99484 applies to care management services for general behavioral health integration (BHI). It covers services that a clinical staff member provides under a physician’s direction to manage a behavioral health condition. You can report CPT 99484 to cover at least 20 minutes of these services in one calendar month under the following required circumstances:

  • The patient requires an initial assessment or monitoring using applicable rating scales.
  • The patient receives behavioral health care planning for psychiatric or behavioral health conditions, which includes revisions for any patient who changes their status or does not progress.
  • The provider coordinates and facilitates care such as counseling, psychotherapy, pharmacotherapy or psychiatric consultation. 
  • A designated care team member provides continuity of care.

It’s easy to assume that CPT 99484 is in the same category as CPT codes 99494, 99493 and 99492, but these three codes apply in different circumstances. They apply to services provided within the Psychiatric Collaborative Care Model (CoCM). CoCM has requirements that set it apart from a typical care management program, so providers rarely use it in conjunction with CCM.

Remote Physiological/Patient Monitoring Device Codes

Remote physiological monitoring (RPM) allows providers to monitor certain chronic and acute health conditions from their patients’ homes, reducing infection risks and travel costs. When providers use RPM, they receive medical data and images from their patients via connected devices. When devices submit patient vitals, the patient’s chart automatically stores their metrics for care providers to assess.

CPT code 99453 covers RPM device setup and education that teaches patients how to use their connected devices and best practices such as the best times to take measurements. You can bill CPT 99453 when a patient first enrolls in an RPM program under their care provider’s recommendation, and you can only bill it once per patient.

CPT code 99454 covers the monthly cost of supplying and provisioning connected devices. You can bill CPT 99454 every 30 days, and it covers a device’s cost if a provider purchases it or leases it for their patient. A qualified health care provider must order the shared device for the code to be billable, and the patient must enter device readings for at least 16 out of the device period’s 30 days. 

How Can ChartSpan Help?

ChartSpan can help your practice by providing comprehensive solutions for Chronic Care Management. Proper medical billing is an important part of CCM because it ensures your practice receives the right reimbursement for the services you provide. 

Our CCM solutions help you manage your practice’s services and use the correct billing codes for each patient. With ChartSpan, you can increase your monthly revenue and retain your Medicare patients. ChartSpan supports you with billing CPT codes 99490 and G0511, giving you more time to focus on caring for your patients. 

At ChartSpan, we offer a highly experienced care team that will reach out to your enrolled patients every month, serving as an extension of your care team and giving each patient around-the-clock access to a clinician. Our customer success team can also assist with billing-related questions and any denials if necessary. Adding innovative solutions to your care management services can address care gaps to significantly increase your quality scores and improve patient outcomes.

Our CCM solutions also help you do the following:

  • Coordinate care with your patients’ other providers
  • Gain 24/7 support from a triage nurse line
  • Help your patients save money
  • Keep track of patients and ensure they follow provider-developed care plans

Contact ChartSpan to Learn More

Understanding CPT billing rules is crucial to ensuring your practice is reimbursed appropriately and your claims are not denied. ChartSpan offers comprehensive CCM solutions as the nation’s largest and most successful CCM program. We offer CCM solutions for health care systems, hospitals, medical practices and Medicare patients. 

We offer a fully managed CCM that removes unnecessary burdens, giving providers and staff more time to treat and care for patients. When you trust ChartSpan with your Chronic Care Management program, we will address and streamline your administrative and care coordination tasks so they don’t interrupt your practice workflow. 

Our full-service solution helps you reach more patients, enroll them quickly and easily, gain insights on quality of care and receive proper reimbursement. 

Contact ChartSpan to learn more about how we help optimize CCM services and increase your revenue.

Published: January 10, 2023

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