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Billing Guide for Chronic Care Management

The Centers for Medicare & Medicaid Services recognize care management services as critical components of primary care for the health and wellbeing of patients with chronic conditions. The following guide aims to clarify the billing and provision requirements of the most common care management services offered by Medicare.

Traditional Chronic Care Management

Most chronic care management (CCM) is billed under the original definitions and requirements of code 99490. These requirements can be split into practice requirements, patient requirements, and monthly billing requirements
  • Practice Requirements
    For your practice to provide CCM, you must:
  • Use a certified electronic medical record (EMR) technology.
  • Offer patients 24/7 access to their healthcare team. This is often satisfied with an emergency phone line or email connected to the provider's care team.
  • Patient Requirements
    To be eligible to enroll in CCM, a patient must:
  • The patient must give informed verbal or written consent that is documented in the medical record.
  • The patient must be informed about the CCM program, possible cost sharing, and that they can stop CCM services at any time.
  • Have two or more chronic conditions.
  • Some examples include hypertension, high cholesterol, arthritis, diabetes, COPD, depression, obesity, etc.
  • Have had an "initiating visit" (AWV or E/M encounter) in the last year.
  • Monthly Billing Requirements
    When the above requirements are met you utilize the following codes to bill for CCM:
  • At least 20 minutes of clinical staff time directed by a physician or non-physician provider are spent managing the patients health and chronic conditions.
  • A comprehensive care plan must be established, implemented, or monitored.
  • Coding for CCM
    When the above requirements are met you utilize the following codes to bill for CCM:
  • 99490: Billable after the first 20 minutes of CCM furnished by clinical staff under supervision of the provider. Reimburses ~$42.
  • 99439: ?Billable for each additional 20 minutes after 99490, up to a maximum of two times. Reimburses ~$38 per instance.
99490
20 Minutes
+
99490
40 Minutes
Total
+
99490
60 Minutes
Total

Other Care Management Services

Since the introduction of CCM, Medicare has released two new services that are based on CCM, but with slight variations to the requirements and reimbursement. Behavioral Health Integration pays more than CCM and is focused on managing mental and behavioral health conditions while Principal Care Management allows for patients with a single severe chronic conditions.
  • Behavioral Health Integration
    Behavioral health integration (BHI) services are very similar to CCM with the following few differences:
  • A patient can have only one chronic condition, and it must be a mental health condition.
  • A validated assessment must be performed on the patient each month to track progress.
  • This can be completed over the phone, and there are many quick validated assessments in the public domain.
  • Time spent on the validated assessment counts towards the 20-minute requirement.
  • It is capped at 20 minutes, but you can bill BHI and CCM in the same month if you exceed 20 minutes.

BHI is billed each calendar month using the following code:

  • 99484: First 20 minutes of BHI furnished by clinical staff under supervision of the provider.
  • Principal Care Management
    Principal Care Management (PCM) services are very similar to CCM with the following few differences:
  • One complex chronic condition lasting at least three months, which is the focus of the care plan.
  • The condition is of sufficient severity to place the patient at risk of hospitalization or has been the cause of a recent hospitalization.
  • The condition requires development or revision of disease-specific care plan.
  • The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.
PCM is billed each calendar month using the following code:
  • G2064: First 30 minutes of PCM furnished by clinical staff.
When PCM is furnished by a physician, nurse practitioner, or physician's assistant, it is billed under a different code:
  • G2065: First 30 minutes of PCM furnished by physician or non-physician provider.
  • Remote Patient Monitoring
    Remote patient monitoring (RPM) and CC were designed to work well together.
This guide aims to simplify the main requirements for providing and billing for care management services but should not be considered a replacement for a qualified medical billing specialist. You can read more information on service requirements in the CMS Care Management Booklet or by contacting your local Medicare administrator.
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7401 Wiles Rd. #139 Coral Springs, FL 33067

Call us: 1 (800) 648 8831

Elegant, easy-to-use remote patient monitoring (RPM) solutions designed to offer the best experience possible for healthcare workers and patients.

7401 Wiles Rd. #139 Coral Springs, FL 33067

Call us: 1 (800) 648 8831

Elegant, easy-to-use remote patient monitoring (RPM) solutions designed to offer the best experience possible for healthcare workers and patients.

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