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CPT 99490: How to Bill for Chronic Care Management

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Editor’s note: This article has been updated to include information about HCPCS code G2058, introduced in the Physician Fee Schedule for CY 2020 and effective January 1, 2020.

Billing for CPT 99490 and related codes requires knowledge of the CMS Chronic Care Management (CCM) program as a whole, as well as an understanding of how the program is broken down for billing purposes. Read on to learn the ins and outs of billing for CPT 99490.

What is Chronic Care Management?

Chronic Care Management refers to care coordination provided outside of the regular office visit, for patients with multiple chronic conditions. In 2015, Medicare began offering monthly reimbursements for these types of services. Non-complex CCM services, billed under CPT 99490, includes at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, and encompasses the following elements:

  • Use of Certified EHR Technology (required in order to bill CCM codes, though no longer required for CCM documentation or transitional care management documents)
  • 24/7 Access & Continuity of Care
  • Comprehensive Care Management
  • Comprehensive Care Plan
  • Management of Care Transitions
  • Home- and Community-Based Care Coordination
  • Enhanced Communication Opportunities

Note that an initial visit is required for new patients or patients that have not been seen in the past year. This could be an Annual Wellness Visit or Initial Preventive Physical Exam, or other face-to-face visit with the billing practitioner. Such a visit is not part of the CCM service and is separately billed. In addition, billing practitioners must obtain patient consent before providing or billing for CCM services. (CMS, 2017 2017)

Complex CCM services, billed under CPT 99487, will further include the substantial revision of a care plan, moderate or high complexity medical decision-making, and at least 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

For a more detailed CCM service summary from the Centers for Medicare and Medicaid Services (CMS), click here.

Who Needs CCM?

CCM is intended for patients with multiple chronic conditions expected to last more than a year or throughout a patient’s lifetime, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. (CMS, 2018) A non-exhaustive list of chronic conditions may be found in the CMS Chronic Conditions Data Warehouse.

The goal of any CCM program is to improve care and outcomes for these types of patients. Providing more comprehensive care management for someone with a chronic condition, or a constellation of chronic conditions, will improve the quality of life of the individual, decrease their individual financial burden in terms of medical costs, and ultimately lead to a healthier, longer life. Providers and payers will also see benefits from improving the long-term health of patients with chronic conditions.

What practitioners are eligible to bill for CCM, including CPT 99490?

Several different types of practitioners may bill for CCM, including:

  • Physicians
  • Non-Physicians:
    • Physician Assistants
    • Nurse Practitioners
    • Certified Nurse Midwives
    • Clinical Nurse Specialists

Other clinical staff may provide the CCM service if they are working under the general supervision of an eligible practitioner. Federally Qualified Health Centers, Rural Health Clinics, and Critical Access Hospitals can also bill for CCM services. Note that if two practitioners in the same practice provide CCM for a patient, only one may bill for the code in any given month.

Patient Agreement and Consent

As mentioned above, providers must obtain a patient’s verbal or written agreement before providing or billing for CCM services. Medicare wants to ensure that patients understand the types of medical services that may be offered, as well as their possible financial obligations. Consent must be documented in the patient’s medical record, and must show that the patient was informed of:

  • The availability of CCM services
  • Any applicable cost-sharing, including the patient’s deductible, co-pay, and co-insurance
  • That only one practitioner can furnish and be paid for CCM services during a calendar month
  • The right to stop CCM services at any time (effective at the end of the calendar month)

Center for Medicare and Medicaid Services, 2017

How do I bill for CPT 99490?

In order to bill for CPT 99490, you must:

  • Document that appropriate clinical staff spent at least 20 minutes of non-face-to-face time providing CCM services within a given month.
  • Record the date, time spent, name of provider, and the services provided.
  • Bill Medicare using CPT code 99490. This may only be billed once per month per participating patient.

Also be sure to:

  • Include the diagnosis codes for the patient’s chronic conditions.
  • Document the time spent in total minutes, not timestamps, and do not round up.

In addition to CPT 99490 (CCM Services) and CPT 99487 (Complex CCM Services), you may also need to use the following service codes that provide payment for coordinated care:

  • CPT 99489 – this is an add-on code to complex CCM (CPT code 99487) for each additional 30 minutes of clinical staff time.
  • HCPCS code G0506 is an add-on code to the CCM initiating visit that describes the work of the billing practitioner in a comprehensive assessment and care planning to patients outside of the usual effort described by the initiating visit code. Remember that the initiating visit itself is not considered to be within the scope of CCM services.
  • HCPCS code G2058 (announced for CY 2020, effective January 1, 2020) – while a provider bills CPT 99490 for the first 20 minutes of clinical staff time spent performing CCM services in a calendar month, G2058 can be used for the second and third 20-minute increments.

Do you have more procedural CCM billing questions for CPT 99490 or related CPT codes? Check out this handy CMS FAQ on Billing for CCM.

How can BlueFish Medical help you?

If you are considering whether to offer CCM services or have been struggling to implement CCM services at your practice, BlueFish Medical can help. BlueFish can extend your medical practice by identifying eligible patients, recruiting and signing them up, creating customized care plans, delivering care with our nursing staff and then billing for the services. Our documentation is entered in your EHR and we will bill the claims on your practice management system. We use our custom developed BlueFish CCM application to ensure compliance.

By managing a practice’s CCM services, BlueFish is freeing up providers to focus on face-to-face encounters, while also realizing reimbursements for non face-to-face visits to which they no longer have to dedicate their time. Providers can expect to net around $36 per patient per month for CCM services, or more if using add-on code G2058. If a practice has 1,000 patients in their CCM program, the program could realize a reimbursement of at least $36,000/month, or $432,000/year. BlueFish earns a percentage of the reimbursement, and the practice gains the dual benefit of an improvement in the health of their patient population and revenue that it would not otherwise have generated.

To request more information about how BlueFish Medical can introduce a successful CCM program to your practice, please fill out the form below.

    Additional Resources:

    Sources:

    Centers for Medicare & Medicaid Services. (2017). Connected Care: Health Care Professional Toolkit. Retrieved from: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Connected-Care-HCP-Toolkit-508.pdf