Chronic Care Management

CCM program outlines

CMS offers a range of billing options that enable healthcare organizations with a substantial opportunity to treat patients with Chronic disease. Alternatives vary by the time spent on care management, who provides the services, and the complexity of patient conditions. One is for non-complex patient services delivered by clinical staff and supervised by a physician. Another is for complex patient services delivered by clinical staff and supervised by a physician. The third is for physician-driven patient services.

There are some conditions attached by CMS. One is that only one series of CCM codes can be billed per patient, per calendar month. You can only submit one claim per patient for either non-complex, complex or physician-driven services per month. Finally, improper billing can lead to claims being denied. Healthcare organizations should consider dropping the claim with the highest reimbursement amount. Another important aspect of chronic care management billing is to use at least two ICD-10 codes with the CPT code.

In summary:
  • CCM requires two or more chronic conditions
  • Each chronic condition requires an ICD-10 code
  • At least two ICD-10 codes are required for billing CCM
  • ICD-10 codes are tied to the conditions you are managing for the patient's CCM
  • If you are managing more than two, you will need an ICD-10 code for each condition managed
Finally, clinical staff is considered to be:
  • Certified nurse assistant (CNA)
  • Certified medical assistant (CMA)
  • Certified nurse specialist (CNS)
  • Nurse practitioner (NP)
  • Physician assistant (PA)

Clinical Staff Non-Complex Chronic Care Management

CPT codes and billing options

The CPT code for staff non-complex chronic care management is 99490.
  • CPT code 99490 is for 20 minutes per calendar month of non-face-to-face CCM services
  • The current national reimbursement is around $62
  • There is also an add-on code for code for code 99490 (code 99439)
  • Code 99439 can be used only as an add-on to code 99490
  • CPT code 99439 pays for an additional 20 minutes of non-face-to-face CCM services
  • It is billed at 40 minutes with code 99490
  • 99490 (99490 20 minutes) + 994399 (20 minutes)
  • Adding 99439 will add approximately $47 of extra reimbursement
  • Can be billed twice per calendar month
  • You would bill 99490 and 99439 times two

clinical staff CCM
CPT billing codes

20 minutes

40 minutes 60 minutes
99490 ($62) 99490 ($62) 99490 ($62)
  + +
    99439 ($47) 99439 ($47)
National average reimbursement   99439 ($47)
$62 $109 $156

Clinical Staff Complex Chronic Care Management

CPT codes and billing options for patients with three or more chronic conditions

The next category is CPT codes for staff complex care management. Complex care management is for patients who have three or more chronic conditions. With this patient group, 60 or 90+ minutes are spent per month on non-face-to-face CCM services. Some patients may have three, four, or five-plus conditions to me managed within a calendar month. The CPT code for staff complex cronic care management is 99487
  • CPT code 99487 is for 60 minutes per calendar month of non-face-to-face CCM services
  • The current national reimbursement average is around $132
  • There is also an add-on for CPT code 99487 with CPT code 99489.
  • CPT code 99489 provides for an additional 30 minutes of non-face-to-face time for CCM services per calendar month
  • CPT code 99489 along with code 99487 are billed at 90+ minutes
  • 99487 (60 minutes) + 99489 (30 minutes)
  • 99489 can be billed an unlimited number per calendar month
  • 99489 is billed at 30 minute intervals: 90, 120, 150+
  • Code 99489 will pay an approximated $70 on top of 99487
Reimbursement for complex clinical staff

One of the reasons to choose Intersect on FHIR as the platform for remotely managing patients with chronic disease, beyond data integration and seamless interoperability, is its ability to manage patients with complex conditions. Many patients have three, four, or even five different chronic conditions. In addition to being able to support the range of medical devices required to monitor a range of conditions, Intersect on FHIR also has the features that enable integrated care teams and an integrated plan of care through the continuum of care.

Clinical Staff
Billing codes

60 minutes 90 minutes 120 minutes 150 minutes
99487 $132) 99487 $132) 99487 $132) 99487 $132)
  + + +
    99489 ($70) 99489 ($70) 99489 ($70)
      99489 ($70) 99489 ($70)
        99489 ($70)
  $132 $202 $272 $342

Physician-Driven Chronic Care Management

What is physician-driven chronic care management? Physician-driving CCM is non-face-to-face services performed by a physician

  • CPT code 99491 is for 30 minutes per calendar month of physician non-face-to-face CCM services
  • The national reimbursement average for code 99491 is $83
  • New in 2022 is a 30-minute add-on CPT code 99437
  • CPT code 99437 is an additional 30 minutes of provider non-face-to-face CCM services
  • Billed at 60 minutes with code 99491
  • 99491 (30 minutes) + 99437 (30 minutes)
  • National average reimbursement $59
  • 99491 ($83) + 99437 ($59) = $142
  • 99437 can be billed an unlimited number of times per calendar month
  • At 30 minute intervals: 60, 90, 120, 150+
  • Code 99437 will pay an additional $59 on top of the 99491

Billing Codes
30 minutes 60 minutes 90 minutes 120 minutes
99491 ($83) 99491 ($83) 99491 ($83) 99491 ($83)
  + + +
    99439 ($59) 99439 ($59) 99439 ($59)
      + +
      99439 ($59) 99439 ($59)
        99439 ($59)
$83 $142 $201 $260

Which Category Should You Choose

Summary and considerations

It is important to realize that, as stated in the program outlines above, you can only bill a patient for only one category during a calendar month. Therefore, you should bill for the category with the greatest amount of reimbursement. The category of non-complex CCM can almost be ruled out. As the add-on CPT code 99437 can only be billed twice per calendar month, reimbursement for this category is capped at $156 per-month based on national reimbursement averages. That amount barely covers the costs associated with the technology. In larger integrated health systems where more clinical staff is usually available, it would be highly inefficient for providers to be saddled with tasks that could be provided by lowered credentialed staff. Intersect believes that whenever possible, the clinical staff complex CCM management is the best choice. For patients not meeting that criterion, CPT codes for remote patient monitoring should be considered in lieu of CCM codes.

Regardless of the amount of revenue from reimbursements, that will be less than the organizational savings due to a reduction in ED visits and readmissions. That savings will be a factor of the cost per each incident times the reduction in their number.

In a recent study of Asthma patients at Northwestern Medicine, the medial length of time between who had follow-up visits with their provider was 131 days while the median length of time between exacerbations for patients WHO DID NOT see their outpatient provider within one month was 46 days. Remote patient monitoring works! U.S. Patent Pending

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