Rules for CPT 99490 and the Other Chronic Care Management Codes

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Rules for CPT 99490 and the Other Chronic Care Management Codes
by Don Daily

If you've come to read this blog post, you're presumably looking for the rules you should be following to perform proper chronic care management billing and coding. That's good, because as we know, while the federal government has been increasingly supportive of care management programs, they are also more closely scrutinizing chronic care management reimbursement by auditing instances and causes of overpayment associated with incorrect billing of the service.


And there's every reason to believe that CMS will be paying even closer attention to chronic care management (i.e., CCM) going forward as the agency is putting substantial money behind the care management service, which provides coverage for patients with 2+ chronic conditions for a continuous relationship with their care team. Thus, the importance of ensuring that you appropriately and consistently following the rules of CCM codes and CCM billing has probably never been greater.

Now let's breakdown what are considered the most common and frequently used chronic care management CPT codes.

CPT 99490 and CPT 99491: Initial CCM Codes

We begin with the base chronic care management CPT code, which was introduced in 2015, and what's often referred to as 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

Coding for CPT 99490 assumes 15 minutes of work by the billing practitioner per 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

When reviewing the requirements for CPT 99490 and CPT 99491, can you tell where they differ? Under CPT 99490, clinical staff supervised by a physician or other qualified healthcare professional can perform CCM for billing purposes. CPT 99491 compensates physicians or other qualified healthcare professionals for time spent on CCM-related care and requires them to provide such care personally. It also requires a minimum of 30 minutes a month of CCM instead of the 20 minutes required under CPT 99490.

CPT 99439 and CPT 99437: CCM Add-On Codes

Now let’s look at the two CCM add-on codes: CPT 99439, which replaced HCPCS code G2058 in 2021, and CPT 99437, which was add 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.

When to Report CPT 99439

CMS established payment for HCPCS code G2058 in its 2020 physician fee schedule final rule and then decided one year later to replace G2058 with CPT 99439. This code can be reported no more than twice per calendar month with CPT 99490 to capture additional care that exceeded the established 20-minute time allotments.

CPT 99437

Chronic care management services each additional 30 minutes by a physician or other qualified health care professional, per calendar month.

When to Report CPT 99437

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

Now we'll move into the complex CCM codes, which were introduced in 2017 when the CCM benefit was expanded. As we define in our glossary, complex CCM is "… is for patients with two or more qualifying conditions who require more clinical staff and physician time" than CCM. In other words, these are patients who must also require moderate- to high-complexity medical decision-making. We begin with 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

With the main complex CCM code explained, we can look at its sole add-on code.

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, it should be reported in conjunction with CPT 99487 when a patient requires an additional 30 minutes of care in the month — which is on top of the 60 minutes covered under CPT 99487.

99424 and 99426: Initial Principal Care Management Codes

Now let's discuss the principal care management (PCM) codes. PCM is defined in our glossary as follows: "A service that provides additional care to patients with one or more chronic conditions by focusing care solely on one such condition. Like chronic care management, principal care management offers an avenue of reimbursement to physicians for the additional work they do while caring for high-risk, complex patients. Examples include medication reconciliation and adjustments, creating a care plan, and patient follow-up."

We begin by discussion the two main PCM codes that took effect in 2020. The codes were originally HCPCS G2064 and HCPCS 2065. They were replaced by CPT 99424 and 99426, respectively, in the 2022 Medicare physician fee schedule final rule.

99424 (was G2064)

Principal care management services, for a single high-risk disease, first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month, with the following required elements:

  • One complex chronic condition expected to last at least 3 months, and which places the patient at significant risk of hospitalization, acute exacerbation/decompensation functional decline, or death
  • The condition requires development, monitoring, or revision of disease-specific care plan
  • The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities
  • Ongoing communication and care coordination between relevant practitioners furnishing care

99426 (was G2065)

Principal care management services, for a single high-risk disease, first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month, with the following required elements:

  • Initial assessment or follow-up monitoring, including the use of applicable validated rating scales
  • Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes
  • Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation
  • Continuity of care with a designated member of the care team

Difference Between 99424 and 99426

The difference between these two codes and CPT 99490 and 99491 are similar, just reversed. G2064 is reported when a physician or other qualified healthcare professional performs the service (like 99491) whereas G2065 is reported when clinical staff — under the direction of a physician or other qualified healthcare professional — performs the service (like 99490).

99425 and 99427: Principal Care Management Add-On Codes

In the 2022 Medicare physician fee schedule final rule, CMS finalized the addition of four new PCM codes. There was CPT 99424 and CPT 99426, which replaced G2064 and G2065, as we just discussed.

CMS also finalized two new add-on PCM codes, CPT 99425 and CPT 99427.

99425

Each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure).

99427

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 99425 and 99427

As add-on codes, they should never be listed on its own. Rather, CPT 99425 and 99427 should be reported in conjunction with CPT 99424 or 99426, respectively, when a patient requires an additional 30 minutes of care in the month.

PCM Now Mirrors CCM

As a result of these principal care management additions, the PCM codes now mirror the existing chronic care management code structure: There are initial and add-on codes for services personally provided by physicians and qualified healthcare professionals and services provided by clinical staff.

CPT 99453 and CPT 99454: The Remote Physiological Monitoring Device Codes

Now we’ll look at the two CPT codes used when remote physiological monitoring — sometimes referred to as remote patient monitoring or RPM — are added to chronic care management: CPT 99453 and CPT 99454.

CPT 99453

Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.

CPT 99454

Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.

When to Report CPT 99453 and CPT 99454

CPT 99453 is reported when a patient is initially enrolled into a remote physiological monitoring program. It can only be reported once for a patient and generates a single payment.

CPT 99454, on the other hand, is reported for the ongoing delivery of RPM services and can be billed on a monthly basis. This code typically requires at least 16 days of data to be collected every month. There is a temporary waiver, put in place during the COVID-19 public health emergency, permitting the reporting of CPT 99454 when two days of data is collected. However, this requires meeting specific exceptions identified under the waiver. Learn more about the measurement-days requirements here.

HCPCS G0506: CCM Care Planning Code

In this section, we'll briefly discuss HCPCS G0506, an add-on code introduced in 2017.

HCPCS G0506

Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service).

When to Report HCPCS G0506

As an FPM Journal article notes, G0506 "… extends payment for CCM initiating visits that require extensive face-to-face assessment and care planning by the billing provider." This care planning, the journal states, should go beyond the usual effort described by the evaluation and management, annual wellness visit (AWV), or initial preventive physical examination code (IPPE).

HCPCS G0506 can be billed separately from the monthly care management service codes — CPTs 99490, 99491, 99487, 99489 — but the time and effort described by G0506 cannot also be counted toward another code. Like the AWV and IPPE, G0506 can only be billed once per patient per provider.

HCPCS G0511: Rural Health Clinic and Federally Qualified Health Center CCM Code

In 2018, HCPCS code G0511 took effect and became the go-to chronic care management code for rural health centers (RHCs) and federally qualified health centers (FQHCs).

HCPCS G0511

Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month.

How HCPCS G0511 Works

Since 2018, RHCs and FQHCs are expected to use HCPCS code G0511 when the requirements for the non-complex or complex CCM CPT codes are met.

Payment for HCPCS G0511 is established by averaging the national non-facility physician fee schedule payment rate for CPT codes 99490, 99487, 99491, and 99484 (discussed next).

CPT 99484: Mental Health CCM Code

Finally, let’s discuss CPT 99484. Taking effect in 2018, this code is reported for general behavioral health integration (BHI) care management services.

CPT 99484

Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month, with the following required elements:

  • Initial assessment or follow-up monitoring, including the use of applicable validated rating scales
  • Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes
  • Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation
  • Continuity of care with a designated member of the care team

What About CPT 99492, 99493, and 99494?

CPT 99484 is often discussed in conjunction with three other CPT codes 99492, 99493, and 99494. In simple terms, these three codes describe psychiatric collaborative care management services delivered under the Psychiatric Collaborative Care Model (CoCM). COCM is rarely used in the same context as CCM and BHI as it includes requirements that are largely outside the scope of a standard care management program.

Meanwhile, as CMS notes, "CPT code 99484 is used to bill monthly services delivered using BHI models of care other than CoCM that similarly include service elements such as systematic assessment and monitoring, care plan revision for patients whose condition is not improving adequately, and a continuous relationship with a designated care team member. CPT code 99484 is also used to report models of care that do not involve a psychiatric consultant, or a designated behavioral health care manager."

To learn more about BHI services and these CPT codes, reference this helpful CMS resource.

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