Coding and Billing for Chronic Care Management

The federal government has been increasingly supportive of care management programs. However, it is also more closely scrutinizing chronic care management reimbursement. It's important to ensure that you appropriately and consistently follow the rules of CCM codes and CCM billing. Expect more auditing to investigate causes of overpayment associated with incorrect billing of the service (more about this later in the chapter).

Rules for CPT 99490 and the Other Chronic Care Management Codes

Let's explore the most common and frequently used chronic care management CPT codes.

CPT 99490 and CPT 99491: Initial CCM Codes

We start our discussion about chronic care management coding and billing with the basic chronic care management CPT code, introduced in 2015, and its sister CPT code, which became effective in 2019. Together, these two CCM codes are sometimes referred to as the non-complex CCM codes.

CPT 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, 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.

CPT 99490 assumes 15 minutes of work by the billing practitioner each month.

 

CPT 99491 Chronic care management services, provided personally by a physician or other qualified healthcare 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.

Difference Between CPT 99490 and CPT 99491

The between CPT 99490 and CPT 99491 is subtle but significant. Under CPT 99490, clinical staff supervised by a physician or other qualified healthcare professional can perform CCM for billing purposes. CPT 99491, on the other hand, compensates physicians or other qualified healthcare professionals for time spent on CCM-related care and requires them to provide such care personally. CPT 99491 also requires a minimum of 30 minutes a month of CCM versus the 20 minutes required as per CPT 99490.

CPT 99439 and CPT 99437: CCM Add-On Codes

These are two CCM add-on codes: CPT 99439, which replaced HCPCS code G2058 in 2021, and CPT 99437, which were added for 2022 in the 2022 Medicare Physician fee schedule final rule.

CPT 99439 Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.

CPT Reimbursement CCM

When to Report CPT 99439

As an add-on code for CPT 99491, it should only be billed for time spent beyond the initial 30 minutes spent providing services under 99491.

CPT 99487: Initial Complex CCM Code

Introduced in 2017 when the CCM benefit was expanded, this is a more complex CCM code. As we define in our glossary and noted earlier in this guide, complex CCM is intended for those patients with "two or more qualifying conditions who require more clinical staff and physician time" than non-complex CCM. In other words, these are patients who must also require moderate- to high-complexity medical decision-making. Let's look at the main CCM code.

CPT 99487 Complex chronic care management services, 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
  • Establishment or substantial revision of a comprehensive care plan
  • Moderate or high complexity medical decision making
  • 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month

CPT 99489: Complex CCM Add-On Code

Now let's look at the add-on code to CPT 99487.

CPT 99489 Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure).

When to Report CPT 99489

As the end of the description for CPT 99489 suggests, this code should not be listed on its own. Rather, report in conjunction with CPT 99487 when a patient requires an additional 30 minutes of care in the month. This comes on top of the 60 minutes already covered under CPT 99487.

2023 Chronic Care Management CPT Codes

CPT Code Service Staff Type Care Management Time Billing Units/Month (Max) Reimbursement
99490 CCM Clinical First 20 minutes 1 ~$63
99439 CCM Clinical Each additional 30 minutes 2 ~$48
99491 CCM Physician or qualified healthcare professional At least 30 minutes 1 ~$85
99437 CCM Physician or qualified healthcare professional Each additional 30 minutes No limit ~$60
99487 Complex CCM Clinical First 30 minutes 1 ~$133
99849 Complex CCM Clinical Each additional 30 minutes No limit ~$70

Other Relevant Care Management Codes

In addition to these chronic care management codes, there are complementary services that are often billed with CCM by organizations that have developed a comprehensive care management program. Three examples are remote physiological monitoring (sometimes referred to as remote patient monitoring or RPM), behavioral health integration (BHI) care management services, and, less frequently, principal care management (PCM). Read more about these codes here or reference this helpful CMS resource. You can also learn more by reading this Medical Economics column written by Prevounce's Daniel Tashnek.

OIG Audit Reveals Chronic Care Management Overpayments

In mid-2021, the federal Office of Inspector General (OIG) conducted an audit covering nearly 8 million claims submitted by physicians and more than 240,000 claims submitted by hospitals for non-complex and complex chronic care management services provided in 2017 and 2018.

The results of this audit have short- and long-term implications for providers of CCM services as well as software vendors. Here are the most important things to understand about the audit and its consequences:

  • Why OIG performed the CCM audit — The agency specifically focused on whether payments made by the Centers for Medicare & Medicaid Service (CMS) for the two types of chronic care management services — non-complex and complex — during 2017 and 2018 complied with federal requirements. As OIG notes, "CCM services are a relatively new category of Medicare-covered services and are at higher risk for overpayments." This audit expands on the findings of a previous audit that found CMS lacked sufficient controls to effectively ensure Medicare payments for non-complex CCM services during 2015 and 2016 complied with federal requirements.
  • What the latest chronic care management audit found — The audit determined that there were nearly $2 million in overpayments associated with about 50,000 claims for non-complex and complex chronic care management services rendered during 2017 and 2018. From these claims, beneficiaries' cost sharing totaled up to about $541,000. According to OIG, the overpayment errors were attributed to CMS lacking claim system edits to prevent and detect overpayments.
  • What OIG recommended — Among several recommendations from the agency, these are some of the standouts:
    • Direct Medicare contractors to recover the overpayments within the reopening period.
    • Instruct providers to refund up to ~$541,000 which beneficiaries were required to pay.
    • Notify appropriate providers to exercise reasonable diligence in identifying, reporting, and returning overpayments in accordance with the 60-day rule. The 60-day rule, created by the Affordable Care Act, requires providers to use reasonable diligence to identify overpayments via proactive compliance activities to monitor overpayments and investigate potential overpayments in a timely manner.
    • Implement claim system edits to prevent and detect future overpayments for chronic care management services.

Considering Medicare's plans to support the growth of CCM, the audit's results suggest that CMS will be stepping up its oversight of the chronic care management program. What does this mean for practitioners? You'll need to step up your oversight as well and better ensure you are coding and billing properly — or face potential violation penalties. Keeping your CCM program compliant is not difficult, but it requires you to be mindful of the requirements when you set up your clinical and administrative workflows. Choosing a CCM software provider that makes compliance a top priority is extra insurance during periods of increased scrutiny and change.

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