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What is Chronic Care Management: Definition and Key Concepts

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What is Chronic Care Management: Definition and Key Concepts

by Daniel Tashnek

Chronic care management (CCM) made its debut in 2015 when it was rolled out by the Centers for Medicare and 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.

Let's take a step back and answer the following question:

What is Chronic Care Management?

Under Medicare, a “care management service” is one of multiple covered programs that allow a healthcare provider to manage and coordinate patient care between traditional office visits. In addition to chronic care management, common examples of care management services include remote patient monitoring (RPM) and transitional care management.

Chronic care management is a specific care management service that provides coverage for patients with two or more chronic conditions for a continuous relationship with their care team. 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 over the phone), 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 beneficial for patients in terms of ongoing health and wellness support, increased access to appropriate medical resources, enhanced communication with members of their care team, reduction in emergency room visits and hospitalization or readmissions, and increased engagement in their own healthcare. CCM, however, is not just good for patients. CCM benefits for practitioners include improved care coordination; strengthened patient satisfaction, compliance, and engagement; and increased revenue.

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 include:

  • Alzheimer's disease
  • Arthritis
  • Asthma
  • Autism
  • Cancer
  • Cardiovascular disease
  • Dementia
  • Depression
  • Diabetes
  • Heart disease
  • High blood pressure
  • Hypertension
  • HIV/AIDS
  • Lupus
  • Multiple sclerosis

There are other requirements that must be met to code, bill, and get paid for CCM. Learn about these rules and more in this comprehensive Chronic Care Management Coding and Billing Guide.

Coding and Billing for Non-Complex and Complex CCM

The chronic care management 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, explicit consent must be received from patients to enroll them in your CCM program.

These 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 CCM 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. HCPCS G2058 is used for every additional 20-minute increment of service time and may be used up to three times for a maximum of 60 total minutes.

Also worth noting: Medicare's newest CCM program, dubbed principal care management (PCM), is similar to chronic care management but only requires the patient to have one chronic condition instead of two or more. You can learn more about PCM here.

"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.

Physicians, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants may all bill for CCM services. However, only a single practitioner may receive reimbursement per patient for CCM services for a given calendar month, and this practitioner must only report either non-complex or complex CCM for a given patient for the month, never both.

While CCM is most frequently billed by primary care practitioners, specialty practitioners who meet CCM requirements can bill CCM services. Chronic care management is occasionally billed by cardiologists, pulmonologists, nephrologists, and other specialists who manage multiple chronic conditions and overall care.

Launching a Chronic Care Management Program

Chronic care management is perfectly tailored for most providers and offers a great new revenue stream for participating practices. With more than 67 million Americans enrolled in Medicare or Medicare Advantage plans, and an average reimbursement of $40 for each 20 minutes of CCM time spent on a patient per month. Where does this $40 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 G2058 for the second and third 20-minute increments. In 2021, the payment for CPT 99490 is $42.23, while each add-on G code pays $37.89 and can be reported up to two times. The total reimbursement for at least an hour of non-complex CCM services come out to $118.01, which can make adding a CCM program a significant boon for patients and practices.

Growing a CCM Program: Adding Remote Patient Monitoring and Behavioral Health Integration

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 is a similar service with slightly different requirements that can be provided in conjunction with or in place of CCM. Behavioral health integration (BHI) is nearly identical to the provision of CCM, with the most notable differences being the addition of validated assessment testing to effectively address the needs of behavioral health patients. Each of these specialized care management services are reimbursable on a monthly basis and effectively complement one another, thus further enhancing patient outcomes and experience while generating additional reimbursement for the extra management required.

While chronic care management programs might look different for different providers, successful programs all essentially have at least one thing in common. Creating 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 for practices to abandon their plans. Health technology companies like Prevounce have stepped up to create user-friendly solutions that streamline the provision of CCM services, permitting practices to focus on patient care rather than documentation and logistics.

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