Chronic care management (CCM) made its debut in 2015 when it was rolled out by the Centers for Medicare & Medicaid Services (CMS) as a separately paid service under the Medicare fee schedule. The rationale behind its inception was to offer an avenue of compensation for practitioners who provided care to their patients outside of the normal confines of the average office visit. The introduction of CCM coincidentally led to a more efficient means of care teams proactively engaging and managing patients with problematic chronic diseases, in turn improving outcomes and reducing treatment costs. CCM also gave providers a new opportunity to generate meaning and recurring revenue. Chronic care management has been a win-win for patients and practitioners — and the healthcare system as a whole — for nearly 10 years now.
Before we dive into CCM further, let's take a step back and answer a fundamental question:
What is Chronic Care Management?
Under Medicare, a “care management service” is one of several covered programs that allow a healthcare provider to manage and coordinate patient care between traditional office visits. In addition to chronic care management, perhaps the most common example of another care management service is remote patient monitoring (RPM) — a topic we will return to later in this piece.
Back to CCM. Chronic care management is a specific care management service that provides coverage for patients with two or more chronic conditions and leads to a continuous relationship with their care team and improves care coordination. Under CCM, the patient’s care team can bill for time spent managing the patients' conditions. This includes formulating a comprehensive care plan, interactive remote communication and management (usually via phone or videoconference), medication management, and coordination of care between providers.
Since the provision of CCM falls under Medicare part B, both original Medicare and Medicare Advantage plans reimburse practitioners when CCM services are provided to eligible beneficiaries. Patients become eligible for the program by having two or more qualifying chronic health conditions that are expected to last at least 12 months or until their death, or if the patient's chronic health conditions put them at significant risk of death, acute exacerbation, or functional decline.
Chronic care management is highly valuable for patients. Patients receive ongoing health and wellness support, increased access to appropriate medical resources, enhanced communication with members of their care team, and increased engagement in their own healthcare, leading to significant benefits such as reduction in emergency room visits and hospitalization or readmissions.
Chronic care management is not just good for patients. CCM benefits for practitioners include improved care coordination; strengthened patient satisfaction, compliance, and engagement; and increased — and growable — revenue.
Let's take a quick look at CCM eligibility.
What is a CCM-Eligible Chronic Condition?
Any condition that meets the Medicare criteria can qualify a patient for CCM. Some of the most common examples of qualified chronic conditions include:
- Alzheimer's disease
- Arthritis
- Asthma
- Cancer
- Chronic obstructive pulmonary disease (COPD)
- Dementia
- Depression
- Diabetes
- Glaucoma
- Hyperlipidemia/high cholesterol
- Hypertension/high blood pressure
- HIV/AIDS
- Osteoporosis
To learn more about CCM patient eligibility, download this guide.
Chronic Care Management Billing and Coding
How does billing and coding work for chronic care management? The CCM service period is one calendar month. Practitioners may choose to report their CCM services (i.e., submit claim) at the conclusion of the service period or after completion of the minimum required service time.
The basic (i.e., "non-complex") chronic care management codes — CPT 99490 and CPT 99491 — require that the enrolled patient receiving services has two or more chronic conditions that are expected to last at least 12 months or until death; the chronic condition must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and a comprehensive care plan must be established, implemented, revised, or monitored. Finally, patients must consent to being enrolled in a CCM program.
The non-complex CPT codes are described as follows:
- CPT 99490: Used for the first 20 minutes of a calendar month for the purpose of chronic care management using clinical staff time and directed by a physician or other qualified health professional.
- CPT 99491: For CCM services that total at least 30 minutes per calendar month AND were provided personally by a physician or other qualified healthcare professional.
When Medicare created the chronic care management program, the maximum time allotment eligible for reimbursement was limited, although it included additional guidelines when billing for complex CCM services (more on these below). To encourage practitioner participation in CCM, and in response for requests of fairer compensation, time allotments were expanded in 2020 and can be billed with the following CPT code:
- CPT 99439: This code is used in addition to 99490 and 99491 to capture additional care that exceeded the established 20- and 30-minute time allotments. CPT 99439 replaced HCPCS G2058.
Also worth noting: Principal care management (PCM) is a care management program finalized for 2020 that is similar to chronic care management but only requires the patient to have one chronic condition instead of two or more.
"Complex" CCM codes build on the aforementioned requirements a bit further. To qualify for complex CCM reimbursement, patients must also need moderate- to high-complexity medical decision-making. The complex CCM CPT codes are as follows:
- CPT 99487: For complex CCM services that total at least 60 minutes of clinical staff time per calendar month. This time must be directed by a physician or other qualified healthcare professional.
- CPT 99489: This code is used for each additional 30-minute increment of complex CCM provided to the patient per calendar month.
Who Can Provide CCM Services?
Medicare allows the following healthcare professionals to bill for CCM services:
- Physicians
- Certified nurse midwives
- Clinical nurse specialists
- Nurse practitioners
However, only a single practitioner may receive reimbursement per patient for CCM services for a given calendar month. This practitioner must only report either non-complex or complex CCM for a given patient for the month, never both.
While chronic care management is most frequently billed by primary care practitioners, specialty practitioners who meet CCM requirements can bill for the services. Physician assistants can also deliver CCM services but cannot bill for CCM under their own NPI. CCM is occasionally billed by cardiologists, pulmonologists, nephrologists, and other specialists who manage multiple chronic conditions and overall care.
Rural health clinics (RHCs) and federally qualified health centers (FQHCs) can also bill for CCM using HCPCS G0511, and as of 2024, they can provide and bill remote patient monitoring in conjunction with CCM or PCM or as a standalone service. Learn more about this great new opportunity in this resource.
Chronic Care Management: Getting Paid
Chronic care management is perfectly tailored for most providers and offers a strong recurring revenue stream for participating practices. Nearly 67 million Americans are enrolled in Medicare or Medicare Advantage plans, and it is estimated that more than two-thirds of Medicare beneficiaries 65 years or older have two or more chronic conditions — all of whom would be eligible for CCM. For example, 200 patients enrolled in a CCM program would earn a billing practitioner a minimum of about $146,000 a year. Where does this figure come from?
Medicare provides coverage for practitioners to bill CPT 99490 for the first 20 minutes of clinical staff time spent performing CCM activities in a month, with the ability to then bill CPT 99439 for each additional 20-minute increment. In 2024, the payment for CPT 99490 is about $61. Take 200 patients x $61 x 12 months and you get a little over $146,000.
Each add-on CPT 99439 pays about $47. The total reimbursement for one hour of non-complex CCM services comes to about $155. Multiply that by 200 CCM-enrolled patients and 12 months and you get $372,000. Any way you look at it, adding a CCM program is a significant boon for practitioners and patients.
Learn more about CCM coding and billing in this downloadable guide.
Growing a CCM Program With Remote Patient Monitoring
It is also worth considering which other care management programs you may want to offer when launching a chronic care management program. Remote patient monitoring (RPM) is the care management service most often paired with CCM to create what is typically described as a "comprehensive care management program." RPM is reimbursable on a monthly basis and effectively complements CCM, further enhancing patient outcomes and the patient's care experience while generating additional reimbursement for the extra management required. Get the lowdown on remote patient monitoring coverage and reimbursement in this RPM billing guide.
The Foundation for Chronic Care Management Success
While chronic care management programs might look different for different providers, successful programs all essentially have at least one thing in common. Launching and growing an effective, compliant CCM program requires practice managers, practitioners, and clinical staff to work together to identify and enroll eligible beneficiaries and then establish protocols and routines that work well for everyone.
If coordinating and executing a chronic care management program is proving difficult, there's no need to abandon your plans. Health technology companies like Prevounce have created user-friendly solutions that streamline the provision of CCM and complementary care management services like RPM, permitting practitioners to focus more on patient care rather than documentation, logistics, coding, and billing. See how Prevounce makes CCM work for practices and patients by scheduling a demo of our platform.
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Disclaimer
Health economic and reimbursement information provided by Prevounce is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.
Prevounce encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently.
Prevounce recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters.
Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements.
The coding options listed here are commonly used codes and are not intended to be an all- inclusive list. We recommend consulting your relevant manuals for appropriate coding options.
The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.