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Founder and CEO of ThoroughCare
Chronic Care Management (CCM) is a preventive program that helps patients mitigate their chronic conditions. As covered by Medicare Part B, providers should understand what CPT billing codes matter to the program and how they are used. This can help your organization avoid denied claims and enhance care.
CCM is covered for Medicare Part B patients with a small co-pay. This monthly engagement program offers patients the benefits of personalized care plans and assisted development of self-management behaviors.
CCM is reimbursable under Medicare’s Physician Fee Schedule, paying various rates.
Different CPT billing codes reflect specific types of CCM. The crucial qualifying determinants are who provides program services, complexity of medical decision-making, and the length of time spent with the patient.
Billing code assignment is based on the complexity of medical decision-making.
As shown in the graphic above, CCM billing codes specify Complex and Non-complex chronic care services. Within these categories, codes further reflect different lengths of time spent with patients and the level of physician involvement required.
In some instances, Non-complex CCM can be provided by clinical staff.
For Non-complex CCM, the following CPT codes can be used to account for reimbursement, based on all program requirements being fulfilled (more information on this later in the article).
Two ICD-10s must be presented when billing for chronic care services as the requirement for CCM includes two or more present conditions.
The following codes are designed for non-complex chronic care in which the provider or non-physician practitioner (NPP) is heavily involved. They cannot be billed concurrently with standard CCM CPT codes (reviewed in the prior section).
The value of physicians’ time is reflected in these non-complex, physician-driven codes as CCM services are not reliant on clinical staff:
The following billing codes apply for complex care:
It is important to note the distinction between CPT code 99487, which accounts for 60 minutes of complex chronic care, versus the two CPT codes (99491 and 99437) that account for 60 minutes of physician-driven, non-complex chronic care.
In the case of an audit, you will want to show the correct code was applied based on the compatible situation.
Providers can use CCM to engage patients on a monthly basis between regular appointments.
Delivered through remote interactions, either by phone or a telehealth platform, CCM is billable when at least 20 minutes are spent with the patient performing appropriate tasks.
CCM services can include:
A patient’s CCM eligibility necessitates having two or more chronic conditions expected to last a minimum of 12 months. Additionally, the patient’s doctor must note these conditions 12 months prior to enrollment. They must pose a significant risk of death, acute decompensation, or functional decline.
Individual care plans are created for, and in collaboration with, the patient upon CCM enrollment and determine services rendered. These care plans act as a comprehensive guide to the patient’s goals, health history, and behavior. Medicare Part B covers 80% of this benefit for patients.
CCM billing must be directed by a provider with an NPI number. However, clinical staff can administer most of the program, saving physician time and involvement. Eligible providers include:
Five items are required when submitting a Medicare claim:
It is helpful to know the staff care coordinator assigned to a patient in case of an audit.
Rural health clinics and federally qualified health centers utilize the following HCPCS code for "general care management” to bill for CCM.
This code can be billed in multiple instances. This includes additional 20-minute increments of CCM, and other programs, such as Remote Patient Monitoring or Behavioral Health Integration. However, when billing other programs, their respective requirements must be met separately.
They’re associated costs must also be accounted for separately.
Like with fee-for-service codes, two ICD-10s must be presented when billing G0511.
Providers can offer CCM alongside Remote Patient Monitoring (RPM).
Using digital devices, such as a blood glucose monitor, patients can capture their data and use it to inform condition management.
RPM supports its own CPT billing codes, and these can be billed concurrently with CCM, supporting dual reimbursements. However, all RPM service and time requirements must be met separately from CCM.
This is also the case for rural health clinics and federally qualified health centers. These groups must use HCPCS code G0511, though.
Learn more about RPM billing codes here.
Providers can also pair CCM with Behavioral Health Integration (BHI).
BHI is a monthly care management program that helps Medicare beneficiaries address mental health concerns. When offered with CCM, integrated behavioral health supports a collaborative care model that can improve outcomes and reduce cost.
BHI supports its own CPT billing code that can be billed concurrently with CCM. However, all BHI service and time requirements must be met separately from CCM.
This is also the case for rural health clinics and federally qualified health centers when using HCPCS code G0511. Learn more about BHI billing codes here.
For healthcare organizations, care management programs can drive revenue and support cost savings. Below is a general example of how reimbursement for a CCM program could add up.
The final figure in the graphic does not account for complex or physician-driven CCM services, nor does it include additional billable time beyond the 20-minute minimum. Both could produce a higher figure.
CCM programs offer additional provider benefits, beyond direct reimbursement. They can be optimized to report data, engage and motivate patients, and meet specific quality metrics key to value-based care.
CCM enhances patient engagement and improves care coordination. Personalized care planning can be used to establish and track SMART goals, or identify social determinants of health.
Patients benefit from enhanced engagement, as well as access to a care manager. They have a monthly check-in to ask questions, discuss conditions, and access resources.
A CCM program can generate significant revenue just by billing certain CPT codes. However, elements of the program, especially within a larger healthcare system, can also promote a value-based care model .
ThoroughCare offers end-to-end workflow for Chronic Care Management.
We simplify the process, so providers can focus on engaging patients. ThoroughCare offers:
*Reimbursement rates are based on a national average and may vary depending on your location.
