Article Updated for 2021
Your Guide to Maximizing your CPT 99490 Reimbursement – 2021 Edition
More than 40% of the US population is affected by chronic conditions. The Centers for Medicare and Medicaid Services (CMS) defines chronic conditions as those in which the patient is at significant risk of death, acute exacerbation/decompensation, or functional decline, and are expected to last until the death of the patient. It only makes sense that a health care program designed to promote health maintenance and prevention for the chronically ill is needed. That is why in 2015, CMS began reimbursing providers for a program called non-complex Chronic Care Management (CCM), billed as the new code CPT 99490. The program is intended to service Medicare patients with two or more chronic conditions and is a non-face-to-face service. This focus on care coordination is intended to prevent chronic conditions from worsening – preventing unnecessary hospital admissions and ED visits, saving patients and Medicare money every year.
For a provider to bill for CPT code 99490, the first step is to obtain documented patient consent to participate in the program, ensuring the patient understands and agrees to pay associated copays and deductibles related to the service. Once the patient is enrolled, CCM services require 20 minutes of clinical staff time each month devoted to the patient, which must be documented in a comprehensive care plan. That care plan must then be made available, each month, to all care providers in that patient’s care continuum. This seems simple enough, however, there are several common questions that arise when billing for a CCM program.
1. What are the requirements of a CCM service?
CCM services require documentation of 20 minutes of non-face-to-face care per enrolled CCM patient, per calendar month in order to bill. Care coordination can encompass a variety of activities that benefit patients with chronic conditions such as refilling prescriptions, assessing fall risk, arranging follow-up appointments, requesting medical records, arranging transportation, and updating medical records. All care coordination activities must be documented in a comprehensive care plan. Once the 20 minutes is complete, the provider can bill CPT code 99490 to Medicare for reimbursement.
2. Which types of care providers can participate in Chronic Care Management?
Chronic Care Management services can be performed under general supervision, “incident to” referring to non-physician services or supplies furnished as an integral but incidental, part of a physician’s professional services. Primary care and a variety of specialities qualify to provide these CCM services. Likewise, physicians and the following non-physician practitioners can bill for CCM services:
- Clinical Nurse Specialists
- Nurse Practitioners
- Physician Assistants
- Certified Nurse Midwives
3. Can CCM be billed on the same day as a provider office visit or hospital visit?
Yes, but you will need to use a 25 modifier. Another option is to move the CCM Date of Service (DOS) to the following day for office visits and following discharge for hospital stays. The alternate dates must lie within the billing month.
4. What Date of Service should be used in the claim?
The day 20 minutes of billable time is reached is the best DOS to use in your claim. However, you can use an alternate date as long as the 20 minutes of billable time has been completed on or before the last date of the month in that billing month.
5. Can providers bill more than one CCM claim for a patient per calendar month?
No, CCM claims must be 30 days apart.
6. Are there certain codes or services that can and cannot be billed in the same month as Chronic Care Management?
Qualified healthcare professionals cannot bill for CCM services during the same service period that care management is being provided by another facility or practitioner. In addition, the services listed below and their corresponding codes cannot be billed within the same month as CCM.
- Home Health Care Plan Oversight CPT code G0181
- Hospice Care Supervision CPT code G0182
- Certain End Stage Renal Disease CPT codes 90951 – 90970
- You cannot bill CCM while a patient is in a Skilled Nursing Facility.
You can, however, bill CCM services while patients are in a nursing home or assisted living as long as the facility is not billing for CCM or Home Health Supervision, code G0181. Lastly, new in 2020, you can bill Transitional Care Management (TCM) CPT 99495/CPT 99496 and CCM in the same time month.
7. Is it required to speak to the patient every month in order to bill for Chronic Care Management?
No. While every attempt should be made to reach each enrolled patient every month, it is likely that some patients will choose not to engage in any given month. This does not mean that you cannot bill during a month that the patient cannot be reached. As long as 20 minutes of meaningful clinical staff time, such as chart work and care coordination activities, are completed, you can, and should, bill for the service.
8. Who collects the coinsurance?
The healthcare provider is responsible for collecting the 20% coinsurance for traditional Medicare plans. The cost will vary for Medicare Advantage plans. If CCM is outsourced to a partner, the billing provider is still responsible for collection.
9. How do I actually complete a claim?
Follow these steps to complete a claim for Chronic Care Management:
- Use 99490 for 20 minutes of service, regardless of the time over 20 minutes.
- The place of service should be listed as the provider’s office, or location code 11.
- Bill under Medicare Part B.
- Use the “Date of Service” listed from the clinical record when billing manually.
- If you receive a denial because the patient was in the hospital or provider’s office on the same day they were billed for CCM, you can move the CCM date until the day after without penalty.
- If a patient has a Medicare Advantage plan as primary and Medicare as secondary, and get a denial from the Medicare Advantage plan, you can then submit billing to Medicare for reimbursement.
10. Where can I find more information on Chronic Care Management billing requirements?
A Fact Sheet on CCM is available on the CMS website through this link.
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