What is a CPT Code?
Current Procedural Terminology (CPT codes) are numbers assigned to every task and service a provider administers to a patient, including medical, surgical, and diagnostic services. Insurers use these codes to determine the amount of reimbursement that a practitioner will receive from an insurer for that service.
What is a reimbursement?
Healthcare reimbursement describes the payment that your hospital, doctor, diagnostic facility, or other healthcare providers receive for giving you a medical service.
What is Chronic Care Management (CCM)?
Chronic Care Management encompasses the supervision and understanding of chronic conditions to help patients understand their conditions and improve their quality of life while coping effectively.
Which patients are eligible for CCM?
To qualify for CCM, a patient must have two or more chronic conditions anticipated to last at least 12 months or until death. Chronic conditions can put the patient at severe risk of death, worsening of conditions, functional decline are all qualifying factors for CCM.
What is a chronic condition?
The Centers for Disease Control and Prevention (CDC) defines a chronic condition as, “Conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both. Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States.”
Examples of chronic conditions
- Alzheimer’s Disease – Or related dementia conditions
- Arthritis – Rheumatoid and Osteoarthritis
- Cardiovascular disease
- Chronic Obstructive Pulmonary Disease (COPD)
CCM vs. Complex CCM
There are two different types of CCM. Classic chronic care management and complex chronic care management. Standard CCM can be distinguished from complex CCM by the respective CPT code. Complex CCM uses codes 99487 and 99489. Complex CCM patients’ care teams must have a significant establishment or revision of the care plan and typically communicate more with the care team staff in a calendar month.
Elements of CCM Care
CCM includes a wide range of services by the care team to help patients manage their chronic conditions. The care team knows the ins and outs of the patient’s conditions. Using electronic health records (EHR), there is a structured list of demographics, conditions, medications, and allergies to medications, and an organized plan of care for the patient.
CCM care relies on virtual care, meaning the patient does not have to go to a clinic or hospital to communicate updates on their care plan. The care is conducted virtually in a non-face-to-face setting.
Continuity of care is a vast aspect of CCM. Continuity of care is “An approach to ensure that the patient-centered care team is cooperatively involved in ongoing healthcare management toward a shared goal of high-quality medical care. Continuity of care promotes patient safety and assures the quality of care over time.” Continuity of care allows patients to be interconnected with members of their care team that best know the patient’s needs.
The main CPT Codes that are used for CCM are 99490,99439,99487, 99489, 99491.
CCM CPT Code
The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of healthcare. CCM bridges the gap between face-to-face appointments to improve patient health outcomes.
CCM CPT Code: 99490
CCM CPT Code: 99490 is the most common billing code and can be used every month. There is a required 20 minutes of care provided by a provider or qualified healthcare professional (QHP). The main elements of this CPT code include two or more chronic conditions, which are expected to last 12 months or until the death of a patient. These chronic conditions have to place the patient at severe risk of death, worsening conditions over time, and functional decline. As required by this code, a comprehensive care plan for managing conditions is developed, whether that is establishing, monitoring, revising, or implementing care for the first time. All of these services are a part of CCM CPT code: 99490.
CCM CPT Code: 99491
CCM CPT Code: 99491 can be used every month. There is a requirement of 30 minutes of care conducted by a provider or QHP instead of the 20 minutes. The same exact requirements remain the same for this CPT code. The patient must have two or more chronic conditions that are expected to last 12 months or until death. These chronic conditions also place the patient at risk of death, worsening of conditions, or functional decline. In the 30 minutes of care the patient can expect to receive details about the care plan and how the conditions will be managed overtime, this can include the establishment of a care plan, monitoring, revising, or implementing care for the first time. CCM CPT code: 99491 is different from CPT code: 99490; the main distinguishing factor is the time of care given to a patient in a calendar month.
CCM CPT Code: 99439
CCM CPT Code: 99439 can be used every month. Instead of the required 20 minutes of care provided by a provider or QHP, it is 30 minutes of additional care. For patients to qualify, they must have two or more chronic conditions expected to last at least 12 months or until death. The chronic conditions also must place the patient at severe risk of death, worsening conditions over time, and functional decline. In these additional 30 minutes of care, plans of care are established, monitored, revised. CPT code: 99439 is seen in tandem with CPT code: 99490.
CCM CPT Code: 99487
CCM CPT code: 99487 is the CPT code for complex CCM patients. CCM CPT code: 99487 requires 60 minutes of care directed by a provider or QHP in a calendar month. This code is used when substantial revision is needed to the comprehensive care plan and requires moderate- to high-complexity medical decision-making (MDM). Moderate-to-high-complexity is a scale that providers use to measure the intensity of conditions in a patient. The three main elements that distinguish MDM are the number and nature of the conditions, the complexity of needs, this conclusion is drawn from data, and the risk of morbidity and mortality to the patient.
CCM CPT Code: 99489
CCM CPT code: 99489 is used when there is an additional 30 minutes of care. This code is seen with CPT codes: 99487. When this code is used, a patient will receive 90 minutes of care in the calendar month. This code is used when there is substantial revision that needs to be made to the patient’s care plan.
The reimbursement billing is different for each CPT code under the CCM umbrella, and can differ depending on the provider of care. The national average for each CCM CPT code is as followed:
CCM CPT Code: 99490: $42.84
CCM CPT Code: 99491: $74.26
CCM CPT Code: 99439: $38.00
CCM CPT Code: 99487: $94.68
CCM CPT Code: 99489: $45.00
CCM CPT codes 99487 and 99489 are often seen together and fall under complex CCM care.
CCM CPT codes 99490 and 99439 are often seen together and are standard CCM care. CCM CPT codes 99491 and 99439 are seen in conjunction and cover standard CCM care.