Chronic Care Management

Chronic care management (CCM) services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.

The Centers for Medicare & Medicaid Services (CMS) recognizes that CCM services are critical components of primary care that promote better health and reduce overall health care costs.

CCM Coding

The five CPT codes used to report CCM services are:

• CPT code 99490 - non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability.
• CPT code 99439 - each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified health care professional (billed in conjunction with CPT code99490)
• CPT code - 99487 complex CCM is a 60-minute timed service provided by clinical staff to substantially revise or establish comprehensive care plan that involves moderate- to high-complexity medical decision making.
• CPT code 99489 is each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualified health care professional (report in conjunction with CPT code 99487; cannot be billed with CPT code 99490)
• CPT code 99491 - CCM services provided personally by a physician or other qualified health care professional for at least 30 minutes.

Requirements and Components for CCM and Complex CCM

CCM services that must be documented in the electronic health record (EHR). Covered services include, but are not limited to:

• Management of chronic conditions
  
• Management of referrals to other providers
  
• Management of prescriptions
  
• Ongoing review of patient status

• Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
  
• Patient consent (verbal or signed)
  
• Personalized care plan in a certified EHR and a copy provided to patient
  
• 24/7 patient access to a member of the care team for urgent needs
  
• Enhanced non-face-to-face communication between patient and care team
  
• Management of care transitions
  
• At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by physician or other qualified health care professional
• CCM services provided by a physician or other qualified health care professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management activities

Complex CCM (CPT code 99487)

Shares common required service elements with CCM, but has different requirements for:

• Amount of clinical staff service time provided (at least 60 minutes)
  
• Complexity of medical decision making involved (moderate to high complexity)

Health Care Professionals Who May Furnish and Bill CCM Services

Only one physician or other qualified health care professional who assumes the care management role for a beneficiary can bill for providing CCM services to that patient in a given calendar month. While services may be provided by a clinical staff person, the service must be billed under one of the following:

• Physician
  
• Clinical nurse specialist (CNS)
  
• Nurse practitioner (NP)
  
• Physician assistant (PA)
  
• Certified nurse midwife

Non-physicians must legally be authorized and qualified to provide CCM in the state in which the services are furnished.

Step-by-Step Approach to Adding CCM Services to Your Practice

Chronic care management can help manage your patients’ chronic conditions more effectively, improve communication among other treating clinicians, and provide a way to optimize revenue for your practice. Learn how time spent coordinating referrals, refilling prescriptions, and taking calls or emails from patients and caregivers can contribute towards the required time to bill CCM services.

Read more about chronic care management in the Making Sense of MACRA: Simplifying Chronic Care Management (CCM) supplement.

The AAFP’s Position on CCM Services

The AAFP’s advocacy efforts helped pave the way for Medicare payment for CCM services, giving family physicians an opportunity to be paid for the many services they provide outside traditional face-to-face office visits. The AAFP believes that family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive, and connected health care.

What You Need to Know

Medicare beneficiaries who qualify for CCM services benefit from additional support and resources that help them manage their chronic conditions effectively. More coordinated care leads to better health and decreased overall health care costs. As the health care system transitions from a fee-for-service model to value-based payment, billing CCM services makes it possible for you to be paid for the time and effort you and other care team members invest in caring for your patients who have chronic conditions. Download the FPM Supplement, "Paving the Path to Value: Care Management and Coordination," to learn more about using CCM services.

Approaches to Help Your Practice Get Started

• Identify Medicare Part B patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient. Risk-stratify your patient panel using the AAFP Risk-stratified Care Management Rubric and Algorithm to identify patients who are high risk.
• Prioritize patients at highest risk of hospitalization or have recently been/are regularly seen in the emergency room.
• Start with patients that regularly call into the clinic to manage symptoms or with medical questions.
• Identify patients that may be most likely to benefit from care management based on the number of specialists involved in their care or who have limited social or local family support.
• Identify patients dually eligible for traditional Medicare and Medicaid (not managed Medicaid).
• Identify volume needed to hire additional part-time or full-time staff and then prioritize eligible patients.