Billing Rules for CPT 99490 & Other Chronic Care Management Codes

By Prateek Haswani | March 20, 2024

Chronic Care Management (CCM) plays an efficient role in managing the health of patients suffering from multiple chronic conditions. Chronic Care Management (CCM) services are non-face-to-face services provided to Medicare beneficiaries who have two or more chronic conditions expected to last for at least one year or until the patient’s death.

The Centers for Medicare and Medicaid Services (CMS) acknowledge that CCM services are critical components of primary care and promote better health while lowering the healthcare costs. CCM enables clinicians and healthcare organizations to give ongoing care to patients via remote interactions.

Table of Contents

Here’s a brief guide to chronic care management and billing rules for CCM CPT Codes:

Medicare reimburses the CCM program if at least 20 minutes of patient service is performed each month. To be eligible for CCM, a patient must have two or more chronic conditions, and the physician must report any chronic illnesses a patient experienced 12 months prior to CCM enrolment.

CPT Code 99490

This non-complex CCM is a 20-minute timed service provided by clinical staff once a month to coordinate treatment among healthcare providers and increase patient engagement. The reimbursement rate for this in 2024 is $64 (the amount varies for different locations). The billing criteria includes:

Multiple (two or more) chronic diseases expected to continue for at least 12 months or until the patient’s death.
Chronic conditions that put a patient at high risk of death, acute exacerbation, or functional decline.
A comprehensive care plan needs to be developed, implemented and amended based on ongoing treatment.

CPT Code 99439

This is an add-on code for 99490 and is billed in conjunction with it. Each additional 20 minutes of clinical staff time for CPT Code 99439 led by a physician or other qualified health care professional is reimbursed at a rate of $48 per calendar month (the amount varies for different locations).

CPT Code 99491

Under CPT Code 99491, CCM services provided by a physician or other health care professional are reimbursed for $86 for at least 30 minutes per calendar month (the amount varies for different locations), subject to the following conditions:

Multiple chronic diseases are expected to last for at least a year or until the death of the patient.
Chronic conditions that put a patient at risk of death, acute exacerbation, or functional decline.
A comprehensive care plan needs to be developed, implemented and amended based on ongoing treatment.

CPT Code 99437

The CPT Code 99437 is an add-on code for 99491 is reimbursed for $61 (the amount varies for different locations). Chronic care management services are provided every 30 minutes by a qualified health care provider, clinician, or physician during a calendar month.

How Do I Bill For Chronic Care Management?

Billing for CCM requires meeting the following criteria:

Patients with at least two chronic illnesses.
Chronic conditions are predicted to last at least a year, or until the patient’s death.
There should be a detailed care plan.
A minimum of 20 minutes of care service is provided per month.
The patient’s agreement is on file for undertaking chronic care.

CPT Code 99490 is used for billing chronic care management. It involves time spent providing comprehensive care coordination, reviewing lab or imaging results, and communicating with patients, caregivers, and other healthcare providers.

Embrace Chronic Care Management With HealthArc

Every individual is different and so are their medication and care needs. With HealthArc’s Chronic Care Management System, we formulate a customized treatment plan with comprehensive assessment to assist our patients in returning to their baseline body functioning.

Want to know how our digital health platform can maximize reimbursement and patient outcomes? Book a free demo or contact us at +201 885 5571 to learn more about our healthcare software.

Frequently Asked Questions (FAQs)

What is CPT 99490 and when is it used?

CPT 99490 is the foundational billing code for non-complex chronic care management (CCM) services. It’s used to bill Medicare for at least 20 minutes of non-face-to-face care coordination provided monthly for patients with multiple chronic conditions.

Who is eligible for Chronic Care Management (CCM) services under CPT 99490?

Patients must have two or more chronic conditions expected to last at least 12 months (or until death), and those conditions must place them at significant risk of serious health decline.

How much time must be documented to bill CPT 99490?

Providers must document at least 20 minutes of clinical staff time per calendar month directed by a physician or qualified healthcare professional.

Is it possible to use clinical staff time to meet the billing requirement?

Yes. Clinical staff can spend time on CCM services under CPT 99490 while the doctor is in charge, and that time counts toward the required time, even if they don’t talk to the patient directly.

Do you need the patient’s permission before billing the CCM codes?

Yes. The provider must get the patient’s permission to use the CCM services and pay for them, including the copay and deductible amounts.

What kinds of services does the CCM billing for CPT 99490 cover?

Care coordination services that can be billed under CPT 99490 include planning care, managing medications, coordinating appointments, reviewing tests, reaching out to patients, and updating care plans.

How often can CPT 99490 be billed?

CPT 99490 can be billed once per patient per month, as long as all documentation requirements are fulfilled.

What other CCM codes will be used with CPT 99490?

Add-on codes, such as 99439, will be used for billing for every additional 20 minutes of time spent on care coordination services, which will be up to two units per month.

Can CCM codes be used in the same month as other care management services?

No, only one set of CCM codes will be used per patient per month. In other words, either 99490 or complex codes, including 99487, will be used. In addition, CPM codes cannot be used for billing with other services for the same care activities.

What if the documentation does not support the CCM billing?

Inadequate documentation, such as the lack of consent, care plans, and time, may result in denied claims or Medicare audits

Tags: #ccm, #ccmcodes, #chroniccare, #chroniccaremanagement, #chronichealthcare, #cptcodes