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What is Chronic Care Management?

People with chronic diseases (COPD, cardiovascular disease, diabetes are among the most common) account for 80% of all hospital admissions, are prescribed more medication, and utilize more healthcare resources than the rest of the population.

CMS recognizes management of chronic diseases as a critical component of primary care that contributes to better health and care for individuals. In 2015, to encourage doctors to do more chronic care management (and to compensate those who were already doing so) they added codes specifically for CCM to the physician fee schedule. There have been several additions/modifications to the program since rollout.

For eligible patients, the codes cover time spent establishing, implementing, revising, or monitoring a Comprehensive Care Plan. Services may be billed if a minimum of 20 minutes is spent in a calendar month. In practice, much of this time is spent in the monitoring aspect – speaking with the patient or caregiver.

Perhaps the most important aspects of the program today are that all aspects of covered services may be delivered by clinical staff under the direction of the billing practitioner on an “incident to” basis, and that much may be done by telephone. Eligible clinical staff includes third parties contracted to deliver these services. Although a physician may personally provide CCM services, the coding, time requirements, and reimbursement are different. Most practices, if they participate, use clinical staff, either internal or contracted, to deliver services.

This article has a brief section on each of the following:

Complex vs. Standard CCM
Patient Eligibility
Initiating Visit
24/7 Access & Continuity of Care
Codes & Reimbursement
Comprehensive Care Plan
Certified EHR Technology
Examples of qualifying chronic conditions

Complex vs. Standard CCM: CMS defines Complex Chronic Care Management as different from standard Chronic Care Management (sometimes called “non-complex CCM) in cases where “moderate or high complexity medical decision making” is required. Complex CCM has different codes, different time requirements, and different reimbursements, and assumes higher levels of physician activity. Complex and standard CCM may not both be billed during the same month. Most of this article will focus on how and when clinical staff may provide standard CCM. For more details on delivery and billing requirements when physician delivered standard CCM or when the patient requires complex CCM, contact us. Alternatively, CMS has this excellent fact sheet.

Patient Eligibility: Medicare patients are eligible if they have two or more chronic conditions expected to last at least 12 months, or until the death of the patient. These must be conditions which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

Initiating Visit: For new patients or patients not seen within 1 year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visit with the billing practitioner). This initiating visit is not part of the CCM service and is separately billed. During the PHE, an exception to the face-to-face requirement for this initiating visit allows this visit to be delivered via telemedicine.

Permissions: Only a single practitioner may bill CCM services within a single calendar month. The providing physician must get the patient’s permission to deliver and bill these services (document this in the patient’s record), but that permission need only be given once, at the beginning of delivery of CCM services, or if the patient changes which practitioner delivers these services. The patient may revoke permission at any time.

24/7 Access & Continuity of Care: Patients/caregivers must have 24/7 access to physicians or other qualified health care professionals or clinical staff, to address urgent needs. Continuity of care requires designating a member of the care team with whom the patient is able to schedule successive routine appointments. When third parties are contracted to provide CCM, they will also take many such calls.

Codes & Reimbursement: These are time based codes.

CPT 99490 covers 20-39 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. For 2021, PFS national average payment for this code is approximately $41

Additional time may be billed in 20 minute increments. For time total time 40-59 minutes, bill one unit each of 99490 and 99439 (formerly G2058). For time above 60 minutes, bill one unit of 99490 and 2 units of 99439. For 2021, PFS national average payment for each unit of 99439 is approximately $38

Total time under 20 minutes may not be billed to CCM codes (but may accrue to other billable activities if appropriate).

Supervision: The CCM codes describing clinical staff activities (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required.

Comprehensive Care Plan: This is a person-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed)

The plan must be provided to the patients/caregiver and the electronic version of the plan must be available and shared within and outside the billing practice to individuals involved in the patient’s care.

The comprehensive care plan for all health issues typically includes, but is not limited to, these elements:

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Cognitive and functional assessment.
  • Symptom management
  • Planned interventions
  • Medical management
  • Environmental evaluation
  • Caregiver assessment
  • Interaction and coordination with outside resources, and practitioners and providers
  • Requirements for periodic review
  • When applicable, revision of the care plan

Certified EHR Technology: Structured recording of demographics, problems, medications, and medication allergies using certified EHR technology is required. A full list of problems, medications, and medication allergies in the EHR must inform the care plan, care coordination, and ongoing clinical care.

Examples of qualifying chronic conditions include, but are not limited to, the following:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular disease
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS

CMS has additional resources available regarding chronic conditions. These may be accessed from the CMS website:

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