Chronic Care Management (CCM)
CPT Code Billing Summary

In 2015, CMS unbundled reimbursement for Chronic Care Management (“CCM”) services, recognizing CCM as “a critical component of primary care that contributes to better health and care for individuals.” The original CCM codes were limited to services provided by clinical staff members under a billing provider’s supervision, so CMS created an additional opportunity for CCM reimbursement in the 2019 MPFS. CMS added yet another code to the CCM group in 2020. In the 2022 MPFS, CMS recognized that providers who furnish care to patients with multiple chronic conditions require greater resources by adding one additional CCM code and increasing the valuation of the entire CCM code set.

CCM services consist of establishing, implementing, revising, or monitoring a care plan for a patient with multiple chronic conditions. CCM services typically focus on advanced primary care aspects such as a continuous relationship between the patient and a designated care team member, providing support for chronic diseases, 24/7 access to care, preventive care, and timely sharing of health information, all of which are often performed outside the face-to-face context.

What are the Chronic Care Management (CCM) CPT Codes?

The CPT Code Manual describes each of the CCM codes as follows:

CPT code 99490 ($64)

Chronic care management services, first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;

• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;

• Comprehensive care plan established, implemented, revised, or monitored.

CPT code 99439 (add-on code to 99490) ($48)

Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

CPT code 99491 ($86)

Chronic care management services, first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month, with the following required elements:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;

• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;

• Comprehensive care plan established, implemented, revised, or monitored.

CPT Code 99437 (add-on code to 99491) ($61*)

Chronic care management services each additional 30 minutes by a physician or other qualified health care professional, per calendar month.

Complex Chronic Care Management (CCCM) CPT Codes

CPT code 99487 ($134)

Complex chronic care management services, with the following required elements:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,

• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,

• Establishment or substantial revision of a comprehensive care plan,

• Moderate or high complexity medical decision making; sic.

• 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

CPT code 99489 (add-on code to 99487) ($70)

Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

*Please Note: Reimbursement amounts listed represent a national average; exact reimbursement amounts vary by geographic region. Amounts are based on CMS 2022 non-facility pay rate and are subject to change.

Key Requirements for Billing the Chronic Care Management (CCM) CPT Codes

According to CMS’ Medicare Learning Network July 2019 guidance document titled “Chronic Care Management Services” (the “Guidance”) CCM services (CPT codes 99487, 99489, 99490, 99439, 99491, and 99437) all require the following common elements:

• Initiation Via Face-to-face Visit. For new patients or patients not seen by the billing practitioner within 1 year prior to commencing CCM services, CMS requires initiation of the service during a face-to-face visit with the billing practitioner. This face-to-face visit may be an Annual Wellness Visit, an Initial Preventive Physical Exam, or Levels 2-5 E/M visit. The initiating visit is not part of the CCM service and should be billed separately. Clinical staff time spent on the day of the initiating visit may not be counted toward the time recorded for billing CCM codes.

• Non-Face-to-face Time. Recordable time includes face-to-face and non-face-to-face time spent (a) communicating with patients and/or caregivers, other professionals, and agencies; (b) creating, revising, documenting, and implementing the care plan; and (c) teaching self-management to the patient and/or caregiver.

• Consent. Consent can be verbal or written and must be documented in the patient’s medical record. The billing practitioner must inform the patient about (a) the availability of CCM services and (b) applicable cost-sharing.

• Billing Practitioner. The billing practitioner must be a physician, Certified Nurse Midwife (“CNM”), Clinical Nurse Specialist (“CNS”), Nurse Practitioner (“NP”), or Physician’s Assistant (“PA”). Notably, only 1 practitioner may bill and receive reimbursement for CCM services provided to a particular patient in a calendar month.  Additionally, the practitioner can only bill for either complex CCM (CPT codes 99487 and 99489) or non-complex CCM (CPT codes 99490/99439 or 99491/99437) in a calendar month, not both.  For CPT code 99490/99439, the billing practitioner bills for CCM services provided by clinical staff on an “incident-to” basis.  Non-clinical staff time cannot be counted. On the other hand, CPT code 99491/99437 are limited to services personally performed by a physician or QHCP. Services provided by clinical staff cannot be billed for under CPT codes 99491.

• Patient Eligibility
  • To be eligible for traditional CCM (CPT codes 99490/99439 and 99491/99437), a patient must have 2 or more chronic conditions expected to last at least 12 months or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
  • Complex CCM cannot be billed if the care plan is unchanged or requires minimal change.  For example, CCM services cannot be billed for simply changing 1 medication or adjusting 1 treatment modality.
  • Complex CCM services are identified by “practice-specific or other published algorithms that recognize multiple illnesses, multiple medication use, inability to perform activities of daily living, requirement for a caregiver, and/or repeat admissions or emergency department visits.” Typically, adult complex CCM patients are those who require 3 or more prescriptions and receive other types of therapeutic interventions, such as physical therapy, in addition to the requirements for CCM described above.
• Minimum Time Requirements
  • CPT code 99490 may be billed once per calendar month and requires at least 20 minutes of clinical staff time spent providing CCM services within that period. 
  • CPT code 99439 may be billed for each additional 20 minutes of clinical staff time spent providing CCM services within that period.
  • CPT code 99491 may also be billed once per calendar month but requires at least 30 minutes of physician or QHCP time spent providing CCM services within that period. 
  • CPT coded 99437 may be billed for each additional 30 minutes of physician or QHCP time spent providing CCM services within that period. 
  • CPT code 99487 cannot be billed until a minimum of 60 minutes has been spent providing complex CCM services in a calendar month.
  • CPT code 99489 cannot be billed until a minimum of 30 minutes in addition to the first 60 minutes reported under CPT code 99487 has been spent providing complex CCM services in a calendar month.
• General Supervision. For CPT codes 99487, 99489, 99490, and 99439 that allow for clinical staff time to count toward the required threshold, clinical staff services must be provided under at least general supervision of the billing practitioner. General supervision means the practitioner must provide overall direction and control but does not necessarily need to be physically present when the services are being performed. NOTE: CPT codes 99491 and 99437 are limited to services personally performed by a physician or other QHCP.  Therefore, services provided by clinical staff cannot be billed for under CPT codes 99491 and 99437.
• CCM Service Elements. Described in more detail below, all of the following must be present:
  • Structured recording of patient health information;
  • Comprehensive care plan;
  • Access to care and care continuity;
  • Comprehensive care management;
  • TCM;
  • Home-and community-based care coordination;
  • Enhanced communication opportunities; and
  • Medical decision-making.
• Duplicative Concurrent Billing.
  • CCM services provided to a particular patient can only be billed by 1 practitioner per calendar month. The billing practitioner cannot bill both complex CCM (CPT codes 99487 and 99489) and non-complex CCM (CPT codes 99490/99439 and 99491/99437) in the same calendar month. Additionally, 99490/99439 cannot be billed in the same calendar month as 99491/99437. CCM codes cannot be billed in the same service period as home health care supervision/hospice care supervision codes (HCPCS G0181 and G0182), End-Stage Renal Disease services codes (CPT codes 90951-90970), or TCM codes (CPT codes 99495 and 99496).
  • Complex CCM codes cannot be billed in the same calendar month as prolonged E/M services codes.
  • When 2 or more clinical staff members are meeting about a particular patient, the billing practitioner may only count 1 staff member’s time.
  • CCM codes can be billed in the same service period as RPM, so long as it does not lead to duplicative payment (i.e., the billing practitioner cannot count the same time more than once).
• Co-Pays. Beneficiaries are statutorily subject to a 20% co-pay for all CCM services. 
• CPT Code 99439. CPT Codes 99439 and 99437 cannot be billed more than twice in a given calendar month. Should be billed at such a time when 20 minutes of clinical staff time is spent in a calendar month above and beyond the time required under CPT Codes 99490 and 99491, respectively.

What are the Key Chronic Care Management (CCM) Service Elements?

• Structured Recording of Patient Information. The practitioner must record the patient’s demographics, problems, medications, and medication allergies using certified EHR technology (“CEHRT”).

• Comprehensive Care Plan. Practitioners must develop a person-centered, electronic care plan based on all of the patient’s health issues, with a particular focus on the patient’s chronic conditions being managed and share that care plan with all individuals involved in the patient’s care. A comprehensive care plan typically includes aspects such as a problem list, measurable treatment goals, medication management, and planned interventions, among others.

• Access to Care and Continuity of Care. Practitioners providing CCM are expected to provide patients with 24/7 access to physicians, QHCPs, and/or clinical staff to address urgent needs, including providing the patient with the means to make contact with healthcare professionals where needed.  Patients must also be able to schedule successive, routine appointments with the same designated care team member.

• Comprehensive Care Management. Practitioners must use system-based approaches to provide timely preventive care services and to manage a patient’s medical, functional, and psychosocial needs. Additionally, practitioners must provide oversight and review of a patient’s medication regime to assess the patient’s adherence, potential interactions, and self-management.

• TCM. Practitioners reporting CCM services must manage patients’ transitions between healthcare providers and settings by providing appropriate referrals to specialists and other providers and conducting appropriate follow-up after emergency department visits and discharges from hospitals, skilled nursing facilities (“SNFs”), or other healthcare facilities. This includes timely development and transmission of continuity of care documents to other providers. TCM is a separately billable service.

• Care Coordination. Practitioners must coordinate with home- and community-based clinical service providers and document all communication to and from those providers regarding the patient’s psychosocial needs and functional deficits in the patient’s medical record.

• Enhanced Communication Opportunities. Practitioners must offer opportunities for the patient and the patient’s caregiver to communicate with the practitioner through enhanced communication methods such as secure messaging, internet, or other asynchronous non-face-to-face consultation methods. Providing only telephone access is not sufficient.
• Medical Decision-Making. Complex CCM services (CPT codes 99487 and 99489) must include medical decision-making of “moderate to high complexity.”.

Generate More Revenue And Improve Patient Outcomes By Leveraging CCM CPT Codes With HealthSnap

The Chronic Care Management CPT codes are a valuable opportunity for providers to receive reimbursement for the care they provide to patients with multiple chronic conditions. HealthSnap works with many Federally Qualified Health Centers (FQHCs), hospital systems, Rural Health Centers (RHCs), Accountable Care Organizations (ACOs), and private physician practices to create a CCM program that works for both patients and providers.

We’re committed to helping our clients take advantage of these billing codes and maximize their reimbursements as well as their patient outcomes and satisfaction. To schedule a demo with the HealthSnap team, click here!