Chronic Care Management: Ensuring Proper Documentation and Billing
Chronic care management requires accurate documentation and billing to ensure compliance, reduce denials, and improve patient outcomes. Learn best practices for effective management.
PCP Medical Billing & Coding Alert
Chronic Care Management (CCM) services are a vital component of primary care, recognized by the Centers for Medicare & Medicaid Services (CMS) as essential for improving the health and well-being of Medicare beneficiaries. These services are designed for patients with multiple chronic conditions, typically lasting 12 months or more, and aim to provide continuous care and management outside of in-person visits.
Under the Medicare Physician Fee Schedule (PFS), CCM services are reimbursed for patients with two or more chronic conditions. Importantly, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are not required to provide face-to-face services, as CCM encompasses non-face-to-face care, allowing for broader access to essential health services.
Essential Components of Chronic Care Management (CCM) Services
Chronic Care Management (CCM) services focus on providing comprehensive care for patients with chronic conditions, aiming to improve health outcomes through consistent management. These services extend beyond in-person visits and include the following critical elements:
- Detailed Patient Health Information: Ensuring that patient health data is accurately documented and easily accessible.
- Electronic Care Plans: Maintaining updated, comprehensive care plans that facilitate coordinated treatment across multiple providers.
- Care Transitions and Management: Overseeing patient transitions between different care settings to ensure continuity and reduce risks.
- Efficient Information Sharing: Ensuring timely and secure sharing of patient health information, both within the healthcare team and with external providers.
These elements apply to both complex and non-complex cases, as required. The focus of CCM is on:
- Establishing a continuous relationship with a designated care team member
- Assisting patients in managing chronic conditions and reaching their health goals
- Providing 24/7 access to healthcare and relevant information
- Promoting preventive care and patient engagement
- Encouraging collaboration with caregivers and sharing crucial health data quickly
CCM services are fundamental in managing long-term health conditions, ensuring patients receive comprehensive, coordinated care while helping to reduce overall healthcare expenses.
Examples of Chronic Conditions Managed Through Chronic Care Management (CCM)
Chronic Care Management (CCM) services are designed to support individuals with a wide range of chronic conditions, helping to manage symptoms, improve health outcomes, and prevent complications. Some of the chronic conditions that benefit from CCM services include, but are not limited to:
- Alcohol abuse
- Alzheimer’s disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Asthma
- Atrial fibrillation
- Autism spectrum disorders
- Cancer (breast, colorectal, lung, prostate)
- Cardiovascular disease
- Chronic kidney disease
- Chronic obstructive pulmonary disease (COPD)
- Depression
- Diabetes
- Heart failure
- Hepatitis (chronic viral B & C)
- HIV and AIDS
- Hyperlipidemia (high cholesterol)
- Hypertension (high blood pressure)
- Ischemic heart disease
- Osteoporosis
- Schizophrenia and other psychotic disorders
- Stroke
- Substance use disorders
By providing continuous and coordinated care, CCM helps patients manage these conditions effectively, improving their quality of life and reducing the risk of further complications.
Concurrent Billing Guidelines for Chronic Care Management (CCM) Services
When billing for concurrent services, it's important to follow specific guidelines to ensure compliance and avoid billing errors. Here are the key points to keep in mind:
- CCM Service Restrictions: Complex CCM and non-complex CCM services cannot be billed for the same patient in a single calendar month (i.e., do not report CPT code 99491 alongside codes 99487, 99489, or 99490 in the same month).
- Home Health and ESRD Services: CCM services cannot be billed during the same service period by the same practitioner as HCPCS codes G0181 or G0182 (home health or hospice care supervision) or CPT codes 90951-90970 (specific ESRD services).
- Transitional Care Management (TCM) and CCM: You can report CCM codes (99487, 99489, 99490, 99491) for services provided during the 30-day TCM service period (CPT codes 99495, 99496) by the same practitioner.
- Prolonged E/M Services: Complex CCM services cannot be billed in the same calendar month as prolonged E/M services.
- Time Reporting Restrictions: Time spent on other billed codes cannot be counted toward CCM service codes.
- RHCs and FQHCs: Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) may bill for both CCM and TCM services for the same patient during the same period.
- Remote Monitoring Services: Remote Physiologic Monitoring (RPM) and Remote Therapy Monitoring (RTM) can be billed concurrently with CCM and TCM services, but not both RPM and RTM together for the same patient.
- Consult CPT Instructions: Always refer to the CPT code instructions to confirm which other codes cannot be billed concurrently with CCM.
- Special Billing Restrictions: Additional billing restrictions may apply if you are participating in a CMS-sponsored model or demonstration program.
Adhering to these billing rules ensures that services are properly reported and reimbursed, maintaining compliance with CMS guidelines.
Chronic Care Management (CCM) Codes and Descriptors
Chronic Care Management (CCM) services are essential for supporting patients with multiple chronic conditions. Below are the key CCM codes and their corresponding descriptors:
CCM Code 99437
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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; each additional 30 minutes by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)
Notes:
- (Use 99437 in conjunction with 99491)
- (Do not report 99437 for less than 30 minutes)
- (Do not report 99437, 99491 in the same calendar month with 90951-90970, 99374, 99375, 99377, 99378, 99379, 99380, 99424, 99425, 99426, 99427, 99439, 99487, 99489, 99490, 99605, 99606, 99607)
CMM Code 99439
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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; each additional 20 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)
Notes:
- (Use 99439 in conjunction with 99490)
- (Chronic care management services of less than 20 minutes duration in a calendar month are not reported separately)
- (Chronic care management services of 60 minutes or more and requiring moderate or high complexity medical decision-making may be reported using 99487, 99489)
- (Do not report 99439 more than twice per calendar month)
- (Do not report 99439, 99490 in the same calendar month with 90951 to 90970, 99374, 99375, 99377, 99378, 99379, 99380, 99424, 99425, 99426, 99427, 99437, 99487, 99489, 99491, 99605, 99606, 99607)
- (Do not report 99439, 99490 for service time reported with 93792, 93793, 98960, 98961, 98962, 98966, 98967, 98968, 98970, 98971, 98972, 99071, 99078, 99080, 99091, 99358, 99359, 99366, 99367, 99368, 99421, 99422, 99423, 99441, 99442, 99443, 99605, 99606, 99607)
CMM Code 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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, moderate or high complexity medical decision making; first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
Notes:
- (Complex chronic care management services of less than 60 minutes duration in a calendar month are not reported separately)
CMM Code 99489
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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, moderate or high complexity medical decision making; 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)
Notes:
- (Report 99489 in conjunction with 99487)
- (Do not report 99489 for care management service of less than 30 minutes)
- (Do not report 99487, 99489 during the same calendar month with 90951-90970, 99374, 99375, 99377, 99378, 99379, 99380, 99424, 99425, 99426, 99427, 99437, 99439, 99490, 99491)
- (Do not report 99487, 99489 for service time reported with 93792, 93793, 98960, 98961, 98962, 98966, 98967, 98968, 98970, 98971, 98972, 99071, 99078, 99080, 99091, 99358, 99359, 99366, 99367, 99368, 99421, 99422, 99423, 99441, 99442, 99443, 99605, 99606, 99607)
CMM Code 99490
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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
- comprehensive care plan established, implemented, revised, or monitored;
The first 20 minutes of clinical staff time are directed by a physician or other qualified health care professional per calendar month.
CMM Code 99491
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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
- comprehensive care plan established, implemented, revised, or monitored;
- The first 30 minutes are provided personally by a physician or other qualified health care professional per calendar month.
CMM Code G3002
This monthly service includes:
- Diagnosis and Monitoring: Regular assessment of the patient’s chronic pain condition.
- Pain Rating Scale Administration: Use of a validated pain rating tool to evaluate the severity and progress of the pain.
- Person-Centered Care Plan:
- Creation, implementation, and continuous updates to a care plan that addresses the patient's strengths, goals, clinical needs, and desired outcomes.
- Overall Treatment Management: Oversight of the comprehensive care plan.
- Behavioral Health Coordination: Facilitating and coordinating any necessary behavioral health treatments.
- Medication Management: Ongoing monitoring and adjustments to medication as needed.
- Pain and Health Literacy Counseling: Educating patients on pain management strategies and improving their health literacy.
- Crisis Care: Addressing any urgent pain-related crises.
- Care Coordination: Regular communication and collaboration with other healthcare providers, such as physical therapy, occupational therapy, complementary approaches, and community-based care as necessary.
Initial Requirements
- Face-to-Face Visit: A minimum of 30 minutes with a physician or qualified health professional is required for the initial consultation.
- Ongoing Monthly Care: The first 30 minutes of care each month must be personally provided by a physician or other qualified healthcare professional. For billing purposes, 30 minutes must be met or exceeded when using G3002.
CMM Code G3003
This comprehensive bundle includes:
- Diagnosis, Assessment, and Monitoring: Regular evaluation of the patient’s chronic pain condition.
- Pain Rating Scale or Tool: Administration of a validated scale to measure pain intensity and changes over time.
- Personalized Care Plan:
- Development, implementation, and ongoing revision of a care plan.
- Includes the patient’s strengths, goals, clinical needs, and desired outcomes.
- Treatment Management:
- Oversight of the patient’s overall treatment.
- Coordination of necessary behavioral health services.
- Medication Management: Monitoring and adjusting medications to manage pain effectively.
- Pain and Health Literacy Counseling: Providing education on managing pain and improving health literacy.
- Crisis Care: Addressing any urgent chronic pain-related issues.
- Care Coordination: Ongoing communication and collaboration among relevant healthcare providers, such as:
- Physical therapy, occupational therapy, and complementary health approaches.
- Community-based care providers, as appropriate.
Required Services
- Initial Face-to-Face Visit: At least 30 minutes with a physician or qualified health professional.
- Additional Care: Each subsequent 15 minutes of chronic pain management, provided by a physician or other qualified health professional, is billed separately (Code G3003), and the 15-minute time requirement must be met or exceeded.
Physician Involvement for Billing CCM Services 99490 and +99439
To bill for Chronic Care Management (CCM) services using codes 99490 and +99439, the physician must play an active role in the patient’s care and provide detailed documentation to support their involvement in overseeing and delivering CCM services.
Here’s how the physician’s involvement is necessary for billing these services:
- Establishing the Care Plan: The physician or other qualified healthcare professional (QHP) must create, implement, modify, or monitor a comprehensive care plan during the reporting month. The plan should address the patient's healthcare needs, set realistic goals, and define the required interventions. While the physician or QHP plays a key role in formulating the plan, the clinical staff typically handles its implementation and monitoring under the physician’s guidance.
- Supervising Clinical Staff: The physician is required to provide direction to the clinical staff involved in care management activities. Their role includes ensuring that staff members follow the outlined care plan and making necessary adjustments as patient needs evolve.
- Documenting Time: The physician should keep thorough records of their time spent on CCM services, including non-face-to-face activities like care coordination, medication management, and communication with patients and caregivers. Accurate documentation is crucial for proper billing.
- Obtaining Patient Consent: Before starting the CCM services, the physician must obtain and document the patient's consent to participate in the program, which can be done either verbally or in writing.
Requirements and Components for Chronic Care Management (CCM) and Complex CCM
|
Component |
Non-Complex CCM (CPT Code 99490) |
Complex CCM (CPT Code 99487) |
|
Chronic Conditions |
Two or more chronic conditions expected to last at least 12 months (or until death) |
Two or more chronic conditions expected to last at least 12 months (or until death) |
|
Patient Consent |
Verbal or signed consent required |
Verbal or signed consent required |
|
Care Plan |
Personalized care plan in a certified EHR, provided to patient |
Personalized care plan in a certified EHR, provided to patient |
|
Patient Access |
24/7 access to a care team member for urgent needs |
24/7 access to a care team member for urgent needs |
|
Communication |
Enhanced non-face-to-face communication between patient and care team |
Enhanced non-face-to-face communication between patient and care team |
|
Care Transitions |
Management of care transitions |
Management of care transitions |
|
Clinical Staff Time |
At least 20 minutes of clinical staff time per calendar month, directed by a physician or QHP |
At least 60 minutes of clinical staff time per calendar month, directed by a physician or QHP |
|
Medical Decision Making |
Not required |
Moderate to high complexity of medical decision making |
|
Physician/Healthcare Professional Time |
At least 30 minutes of personal time for CCM activities (CPT 99491) |
Complex care involves more detailed medical decisions and greater clinical staff time. |
Key Differences
- Complex CCM requires more clinical staff time (at least 60 minutes) and involves a higher level of medical decision-making complexity.
- Non-Complex CCM involves at least 20 minutes of clinical staff time per month, while Complex CCM requires 60 minutes or more.
Why BillingFreedom is the Best Primary Medical Billing Service Provider for Chronic Care Management?
BillingFreedom is the ideal primary care medical billing services partner for chronic care practices, offering expert billing services for Chronic Care Management (CCM). We have a deep understanding of CCM codes like 99490 and 99439, ensuring accurate documentation and compliance with Medicare and CMS guidelines.
Our team efficiently tracks clinical staff time, secures patient consent, and coordinates care plans to ensure proper billing for non-face-to-face services. With our services, chronic care practices can experience reduced A/R days, maximized revenue, and faster reimbursements. We streamline the billing process, minimize denials, and enhance cash flow, allowing your practice to focus on patient care while we handle the complexities of billing.
Trust BillingFreedom to manage your chronic care billing efficiently and effectively.
For more details about our exceptional medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472.
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