Chronic care management (CCM) provides patients with two or more chronic conditions the ongoing care they need to live as healthy of a lifestyle as possible. While the focus of these services is giving patients quality care, compensation is also an important concern for healthcare providers. Following the Centers for Medicare and Medicaid Services (CMS) chronic care management guidelines ensures that healthcare teams adhere to billing protocols and best practices. Acknowledging that this is a complex process, TimeDoc created this blog to offer additional insight into some Medicare chronic care management regulations.
Which Conditions Are Considered Chronic by CMS?
The CMS considers 21 different conditions to be chronic afflictions. Of the ones on that list, these are some of the top conditions that Americans face today:
- Alzheimer’s Disease: In 2020, 5.8 million Americans had this condition. It’s estimated that 14 million will have it by 2060.
- Cancer: This condition is the second leading cause of death in the U.S. One in three people will be diagnosed with cancer in their lifetime. Cancer treatment costs the healthcare system $185 billion a year.
- Diabetes: 37.3 million Americans have diabetes, and 96 million have prediabetes. Treatment for this condition costs the U.S. healthcare system $327 billion a year.
- Heart Disease: This condition is the leading cause of death in the U.S., taking the lives of one in three Americans each year. Heart disease costs the healthcare system $216 billion a year and $147 billion in lost productivity at work due to premature death.
- Stroke: Even though this condition is one of the leading causes of death in the U.S., it’s also preventable and treatable. The chance of having a stroke doubles every 10 years once you reach the age of 55.
For a patient to be eligible for CMS CCM, they must have at least two of these conditions for at least 12 months or until their passing.
What Is Required to Bill CCM?
In addition to treating patients with at least two long-lasting chronic conditions, other CCM billing requirements include:
- You provide patients with a care plan that includes information on their conditions, expected outcome and prognosis, treatment, and more.
- The patients give consent before you provide them with services.
- You record each patient’s health information in an electronic health record (EHR).
- You provide at least 20 minutes of care to the patients each month.
- You call patients to check in with them between scheduled appointments.
- Patients have access to medical support 24/7 in case they have an urgent medical need.
While all these requirements will give patients the care they need to maintain a healthier lifestyle even with multiple chronic conditions, they can place a toll on healthcare providers. It can put extra work on their plates. TimeDoc Health’s platform and services relieve some of that strain by offering you the tools and staff you need to take care of a patient in less time. Plus, our platform helps you maintain Medicare compliance by giving you a place to store monthly encounter summaries, consent forms, and care plans.
Who Can Make Chronic Care Management Calls?
The CMS recognizes that providers are busy and cannot always be the ones to make CCM calls, so they do permit others from your clinical staff to assist. Care coordinators like those who work with TimeDoc Health can make these calls and work as an extension of your team if your staff doesn’t have the time or if you don’t have the staff. Healthcare providers must supervise these calls or any other services that the clinical staff gives. That does not mean that they have to be physically present. Rather, it means they direct what is done or said and the CCM care is billed under their national provider identifier (NPI). Such providers may be one of the following:
- Physician
- Advanced practice registered nurse
- Physician assistant
- Clinical nurse specialist
- Certified nurse midwife
Even if you don’t need extra personnel to make the calls for you, a platform like TimeDoc Health makes it easy to schedule telehealth calls and to share information via the EHR.
Billing Chronic Care Management
The only people who can bill for CCM codes are those we listed in the previous section. It’s important to note that only one provider can bill for CCM per month. Although only one provider is allowed to bill for CCM each month, other clinical staff are not prohibited from providing CCM services.
Due to the monthly billing rule, additional treatment sessions must be billed under codes separate from the CCM CPT codes.
How Much Does CCM Reimburse Per Patient?
The exact amount of reimbursement Medicare pays to care providers depends on a variety of factors, changes regularly, and is laid out in the CMS physicians fee schedule. Solely for illustrative purposes, the national average for CCM reimbursement in 2023 is as follows:
- $61: CCM clinical staff first 20 minutes
- $83: CCM physician or nurse practitioner first 30 minutes
- $130: CCCM (complex chronic care management) clinical staff first 60 minutes
This is the amount that Medicare will pay to care providers, not the whole cost of service or the out-of-pocket patient cost.
How Often Can CCM Be Billed?
Chronic care management billing can be submitted to Medicare monthly. Only one care provider is eligible to bill Medicare for CCM care per patient, and this patient must have signed a consent form for the service beforehand. The minimum of twenty minutes of required monthly clinical staff care can only be billed once per month, with additional time being coded and reimbursed separately.
For more information on practitioner billing of CCM to Medicare, see this FAQ guide from CMS.
What Is the New CPT Code for Chronic Care Management?
The newest CPT code for CCM is 99491, which was established by the CPT Editorial Panel in 2019. To understand the need for this new code, let's examine the web of CPT codes providers commonly use for CCM:
- 99490 applies when a patient has two or more chronic conditions expected to last a year or until the patient passes away. To use this code, clinical staff must spend at least 20 minutes per month coordinating and managing the patient's care under the direction of a physician or other qualified healthcare professional.
- 99439 replaced HCPCS code G2058 in 2022 as an add-on to 99490. This code lets providers bill for an extra 20 minutes of clinical staff time—directed by a qualified healthcare professional—each calendar month after the initial 20 minutes have been captured by CPT code 99490.
- 99491 is the newest CCM code. It is used when the billing practitioner—either a physician or non-physician practitioner (NPP)—does the same work as clinical staff in code 99490, but for at least 30 minutes. Clinical staff time does not count toward the 30-minute threshold for this code.
- 99437 is an add-on to 99491, as it is for each additional 30 minutes of health care time by a physician or NPP.
- 99487 is reserved for complex CCM (aka CCCM), which involves moderate- to high-complexity medical decision-making. The physician or qualified healthcare professional must spend at least 60 minutes per month coordinating and managing the patient's care to use this code.
- 99489 is an add-on to 99487, as it is for each additional 30 minutes of a physician or other qualified healthcare professional's clinical staff time.
Below is a handy chart provided by the CMS that succinctly clarifies each code. Of note, Relative Value Units (RVUs) are a measure of the relative resources required to provide a service or procedure. Additionally, the RVU Update Committee (RUC) is an advisory group that provides recommendations on the valuation of medical services under the Medicare Physician Fee Schedule.
TimeDoc Health’s integrations and automations make CCM billing much more manageable by saving you time on the process.
TimeDoc Health: CCM Billing Made Easy
With TimeDoc Health, you can easily track how much time you spend providing CCM to each patient through our advanced EHR integrations. You do so without interrupting your work by automatically tracking and logging your time in patient charts. Our platform will also streamline your billing processes by automatically tabulating charges based on the activities your team documents in the EHR.
To learn more about how our platform and services can assist you with your CCM program, schedule a demo.