Skip to main content

Complex Chronic Care Management

CPT Codes

99487 - Complex chronic care management services can be billed with following criteria are met

  • 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
  • Establishment or substantial revision of a comprehensive care plan
  • Moderate or high complexity medical decision making

Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not reported separately

99489 - Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure). 

Report 99489 in conjunction with 99487. 

Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month.

Guidelines

60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both).

Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately

Eligible Provider's

  • Physicians and the following non-physician practitioners may bill CCM services,
  • Certified Nurse Midwives
  • Clinical Nurse Specialists
  • Nurse Practitioners
  • Physician Assistants

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)

A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements,

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions and identification of the individuals responsible for each intervention
  • Medication management
  • Community/social services ordered
  • A description of how services of agencies and specialists outside the practice are directed/coordinated
  • Schedule for periodic review and, when applicable, revision of the care plan

Initiating Visit 

  • Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visits not required), for new patients or patients not seen within 1 year prior to the commencement of CCM services.

Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506

G0506 - Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service].

G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.

Note: 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.


Return to CCM Billing

Popular posts from this blog

Usage of CPT Index - Instructions

The alphabetic index is not a substitute for the main text of the CPT codebook. Even if only one code is present, the coder must refer to the main term to ensure that the code is selected accurately and correctly to identify the services rendered. Main Terms The index is organized by main terms. Each main term can stand alone or can be followed by up to three modifying terms. There are four primary classes of main entries, Procedures or Services - E.g, Scopic, Anastomosis, Splint, Opening Organ or Other Anatomical Site - E.g, Knee, Arm, Ear, Tibia, Colon Conditions - E.g, Abscess, Entropion, Tetralogy of Fallot. Synonyms, Eponyms, and Abbreviations. - ECG, EEG, PET, Brock Operations, Clagett Procdures Modifying Terms The main term may be followed by up to three indented terms that modify the terms they follow. EG. The main term "Endoscopy" is subdivided by the anatomical sites in which the procedure is used. And within these anatomical sites, the specific purpose of the pr

Additional Information About Modifiers

Sequencing of modifiers  How can that be if the modifiers used were accurate?  There is an order to reporting modifiers and there are three categories that modifier usage fall under:  1. Pricing  Pricing modifiers are always sequenced “before” payment modifiers and/or location modifiers.   The only exception to this rule is when a global surgery package is involved.  For example, you would code modifier 58 first and modifier 82 second in a global surgery.  A few examples of pricing modifiers are: 22, 26, 50, 52, 53, 62, 80, and P1-P6.   2. Payment   Payment modifiers alert the insurance carrier that there is a special situation within the claim  Some examples of payment modifiers would be: 24, 25, 51, 57, 58, 59, 76, and 78.  3. Location  Examples of location modifiers are: E1-E4, FA, F1-F9, LC, LD, LT, RT, RC, TA, and T1-T9.  The general order of sequencing modifiers is ( 1) pricing (2) payment (3) location. Location modifiers, in all coding situations, are coded “last”.  If you code

Evaluation and Management (E/M) Services - Domiciliary or Rest Home Environment

Domiciliary, Rest Home, or Custodial Care Services CPT codes 99324 - 99337 Domiciliary, Rest Home (e.g. Boarding Home), or Custodial Care Services, are used to report E/M services to individuals residing in a facility which provides room, board, and other personal assistance services, generally on a long-term basis.  These codes are also used to report E/M services in an assisted living facility. The facility’s services do not include a medical component. A home or domiciliary visit includes a patient History, Physical Examination and Medical Decision Making in various levels depending upon a patient’s needs and diagnosis.  The visits may also be performed as counseling and/or coordination of car, when medically necessary outside the office environment and are an integral part of a continuous of the patient's care.  The patients seen may have chronic conditions, may be disabled, either physically or mentally, making access to a traditional office visit very difficult, or may have l