Comprehensive Guide to Chronic Care Management, Billing CPT Codes

Chronic care management (CCM) is valuable in helping healthcare providers deliver ongoing care to patients with chronic conditions. Understanding the correct CPT codes is essential to streamline billing and ensure compliance with healthcare regulations. 

This guide will walk you through the most critical CPT codes related to CCM services to support your ability to provide top-notch care.

Understanding Chronic Care Management Billing Codes

Billing chronic care management codes involves several key CPT codes that reflect different types of care and services provided. 

Below are the most commonly used codes and how to apply them effectively:

CPT Code G0511

This code is used by Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) to cover a wide range of care management services. 

It includes CCM, Principal Care Management (PCM), and Behavioral Health Integration services. You can bill for this code once per month for each patient receiving these services.

CPT Code 99439

This add-on code covers additional 20-minute blocks of non-complex CCM services provided by clinical staff under a physician’s supervision. It is used when more than the minimum time required for CCM is spent in non-face-to-face care.

CPT Code 99490

This foundational code applies to non-complex CCM services, covering the first 20 minutes of care management per calendar month. It is specifically for non-face-to-face time spent coordinating the care of patients with chronic conditions.

CPT Code 99437

Use this code for an additional 30 minutes of CCM care, personally provided by a physician or nurse practitioner. It can be billed in tandem with code 99491 for more comprehensive care services.

CPT Code 99491

This code covers the first 30 minutes of non-complex CCM services provided directly by a physician or other qualified health professionals, offering more personalized care coordination.

Navigating Complex Chronic Care Management Codes

For patients with more severe and complex health issues, these specific codes are used to reflect the intensity of care provided:

CPT Code 99487

This code is applicable for the first 60 minutes of complex care management services, which involve a higher level of decision-making and care planning.

CPT Code 99489

An add-on code for 99487, this covers additional 30-minute blocks of complex CCM services. There's no limit to how many times you can bill this code in a month. 

Chronic Care Management Billing Requirements

To ensure smooth billing and maximum reimbursement, you need to understand the chronic care management guidelines and requirements: 

What Is Needed to Submit CCM Claims to CMS 

You'll need five important pieces of information: 

• The appropriate CPT codes 
• The location or method of service delivery 
• The date(s) of service 
• The ICD-10 codes for the managed conditions 
• Your National Provider Identifier (NPI) number 

How to Submit Your Bill for CCM Services to CMS

• Verify patient eligibility and enrollment 
• Check that appropriate services were provided 
• Submit claims to CMS 
• Invoice patients for copays and other charges 
• Ensure there's no conflict or duplication in billed codes 

The billing process for CCM services requires attention to detail and a systematic approach. Start by verifying that the patient is eligible for CCM services and has been properly enrolled in your program. 

Next, review the services provided to ensure they meet the requirements for the CPT code you're billing. For example, if you're billing 99490, confirm that at least 20 minutes of non-face-to-face care coordination services were provided during the calendar month. 

When submitting claims to CMS, use the appropriate CPT codes and ensure all required information is included. Be prepared for potential audits by maintaining thorough documentation of all services provided.   

Remember, you can only bill one CCM code per patient per month, so choose the most appropriate code based on the level of service provided. 

Invoicing patients for copays and other charges is an important step. CCM services typically require a 20% coinsurance from Medicare beneficiaries. However, be aware that some patients may have secondary insurance that covers this cost. Finally, double-check your billing to ensure there are no conflicts or duplications. 

Who Provides CCM Services 

CCM services can be provided by a range of healthcare professionals, including physicians, PAs, RNs, LPNs, pharmacists, and care managers. While most CCM codes are for non-physician time, physicians can provide these services when necessary. 

How CMS Defines Clinical Staff 

CMS defines clinical staff as personnel working under a physician's supervision, who are legally allowed to provide CCM services. They can be employed by a third-party service if the billing practitioner maintains functional oversight. 

Chronic Care Management Billing Solutions: Frequently Asked Questions  

What insurance covers CCM? 

Medicare is the primary insurer covering CCM services. However, some private insurers are beginning to offer coverage for these services. You should always check with the specific insurer for their CCM policies. 

Who can bill for PCM services? 

A provider can bill for Principal Care Management (PCM) services, but that same provider cannot bill for CCM services—a different provider can. This includes physicians, nurse practitioners, physician assistants, and certain other qualified healthcare professionals. 

Is CCM for Medicare only? 

While Medicare is the main payer for CCM services, some private insurance companies are starting to cover these services. The coverage and reimbursement rates can vary, so it's important to check with each insurer.    

Choose Accuhealth for Your CCM Support 

Understanding the chronic care management billing guidelines can be challenging but not impossible. 

Our team of trained professionals handles patient outreach, education, and enrollment. We provide the required monthly care, including medication management, care coordination, and patient education. The advanced remote patient monitoring technology allows us to track patient health even from hundreds of miles away. 

With Accuhealth, you can focus on what you do best - providing top-quality care to your patients. 

Concierge value-based CCM is just a click away. Schedule a meeting with us to learn more!