Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions. In addition to office visits and other face-to-face encounters (billed separately), these services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients and any care providers (physicians or other clinical staff). The creation and revision of electronic care plans is also a key component of CCM.
- The designated CCM clinician (MD, PA, NP) must establish, implement, revise, or monitor and manage an electronic care plan that addresses the physical, mental, cognitive, psychosocial, functional and environmental needs of the patient as well as maintain an inventory of resources and supports that the patient needs. Thus, the practice must use a certified EHR to bill CCM codes.
- Only one clinician can bill for any particular patient therefore it may be necessary to coordinate with the sub-specialists who may be providing a significant amount of care and treatment to one or more of the patient’s conditions. It will be important that the patients understand only one of their likely multiple physicians will be able to bill for CCM services.
These codes are generally intended for use by the clinician who is providing the majority of the care coordination services, which most often would be the primary care internist. However, certain specialists may be able to provide the services needed to qualify to bill the CCM codes, but never in the same month as the primary care physician.
- Eligible professional (EP) – The CCM codes can only be billed by a physician, advanced practice registered nurse, clinical nurse specialist, or physician assistant.
- Chronic condition – CPT states that patients must have “2 chronic continuous or episodic health conditions that are expected to last at least 12 months, or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”
- Comprehensive Care Plan – This is an electronic summary of the physical, mental, cognitive, psychosocial, functional, and environmental assessments, a record of all recommended preventive care services, medication reconciliation with review of adherence and potential interactions and oversight of patient self-management of medications, an inventory of clinicians, resources, and supports specific to the patients, including how the services of agencies or specialists unconnected to the designated physician’s practice will be coordinated. Including assurance of care appropriate for patient’s choices and values.
- Clinical staff – Licensed clinical staff members (including APRN, PA, RN, LSCSW, LPN, clinical pharmacists, and “medical technical assistants” or CMAs) who are directly employed by the clinician (or the clinician’s practice) or a contracted third party and whose CCM services are generally supervised by the clinician, whether provided during or after hours. Thus the “incident to” rules do not require that the clinician be on the premises providing direct supervision.
- Contact-based care – To count the time towards the 20-minutes of non-face-to-face time, the care must be “contact initiated.” This could be patient-doctor, patient-nurse, doctor-doctor, pharmacy-doctor, lab-doctor, or other contact regarding or by the patient via phone or electronic communication. General planning time or care coordination doesn’t count unless it is initiated based on a contact and/or results in a patient or patient-related contact. For example, if the pharmacist calls the office because the patient reported a rash, then the time counts. If the office spends time running a report of all participants due for a flu shot or an A1C check, that time doesn’t count. When they call and speak to the patient and then coordinate care, then that time would count. In-person visits, including group visits, do not count toward CCM codes.
- Certified CCM technology – CCM codes must be provided by a certified EHR.
- CPT code 99490 – CCM services, at least 20 minutes per month. The 2018 average reimbursement is $42.84 adjusted based on geography.
- CPT code 99487 – Complex CCM services, 60 minutes of clinical staff time per month. Average 2018 reimbursement is $94.68.
- CPT code 99489 – Complex CCM services, each additional 30 minutes of clinical staff time per month. Average 2018 reimbursement is $47.16.
- CPT code G0506 – Care Planning for Chronic Care Management. 2018 reimbursement is $64.44.
- CPT code 99091 – Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time (for 2018 pending anticipated changes in CPT coding). 2018 average reimbursement is $58.68.
- CPT code G0511- General CCM services provided via RHCs and FQHCs for 20 minutes per month. 2018 average reimbursement is $67.03.
- CPT code G0512- Psych, Behavioral CCM services provided via RHCs and FQHCs for 60 minutes per month. 2018 average reimbursement is $145.96.
- CPT code 99495 – TCM services, within 14 day of discharge. The 2018 average reimbursement is $166.50 adjusted based on geography.
- CPT code 99496 – TCM services, within 7 day of discharge. The 2018 average reimbursement is $235.01 adjusted based on geography.
- The practice must have the patient’s written or oral consent in order to bill for CCM services.
- Only one clinician can furnish and be paid for CCM services during a calendar month. The clinician who is providing the primary care to the patient is the one who can bill. Usually this will be the primary care internist, but some specialists may be serving as the patient’s primary care physician.
- Copayments (coinsurance and deductibles) DO apply, unless performed at the same time as the Annual Wellness Visit.
- The following codes cannot be billed during the same month as CCM (CPT 99490):
- Transition Care Management (TCM) – CPT 99495 and 99496
- Home Healthcare Supervision – HCPCS G0181
- Hospice Care Supervision – HCPCS G9182
- Certain ESRD services – CPT 90951-90970
- If other E&M or procedural services are provided, those services will be billed as appropriate. That time can NOT be counted toward the 20 minutes. If time, such as from a phone call, leads to an office visit resulting in an E&M charge, that time would be included in the billed office visit, NOT the CCM time.
- Document patient consent, if they declined to participate, or indicated participation elsewhere (and if so, with whom). Oral consent is acceptable until the next time the patient comes to the office, when they should sign the written consent (but it is not required).
- Document 20 minutes of non-face-to-face clinical staff time. Each practice will need to develop its own consistent system of documentation based on its unique physical, staffing, and EHR configuration. Consideration should include documentation of care provided by both internal and external (such as for call coverage) individuals, who and how care will be documented in the record, and how to document time spent doing different aspects of care and care coordination such as medication refills and referral coordination.