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Chronic Care Management

The Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions from 2015

Guidelines

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored
  • Only one practitioner may be paid for CCM services for a given calendar month.
  • This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both).
  • CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM.
  • The CCM service is not within the scope of practice of limited-license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.
  • CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner),

CPT Codes

99490 - Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month,

99491 - Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes per calendar month,

Eligible Provider's

  • Physicians and the following non-physician practitioners may bill CCM services,
    • Certified Nurse Midwives
    • Clinical Nurse Specialists
    • Nurse Practitioners
    • Physician Assistants
Examples of chronic conditions include, but are not limited to, the following,
  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular Disease
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS
Note:

CPT code 99491 includes only time that is spent personally by the billing practitioner. Clinical staff time is not counted towards the required time threshold for reporting this code.

The billing practitioner cannot report both complex CCM and non-complex CCM for a given patient for a given calendar month. Do not report 99491 in the same calendar month as 99487, 99489, 99490.


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