Chronic Care Management Guide: How to Build a Successful CCM Program

The purpose behind the inception of chronic care management was to provide a means of compensation for physicians and their organizations that were already caring for patients outside of the average office setting. As care teams collaborated outside the confines of a brick-and-mortar facility, patients with persistent and complicated diseases were able to reduce treatment costs while improving their health. Examples of positive patient outcomes include increased access to appropriate medical resources, enhanced communication with members of their care team, reduction in emergency room visits and hospitalization or readmissions, and increased engagement in their own healthcare.

What is Chronic Care Management: Key Concepts

CMS defines chronic care management as:

Care coordination services done outside of the regular office visit for patients with multiple chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbations/decompensation, or functional decline. These services are typically non-face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month.

In addition to chronic care management, common care management services include remote patient monitoring (RPM) and transitional care management. (Learn definitions of other common CCM and preventive services terms in this glossary.)

To qualify for chronic care management participation, patients must be diagnosed with two or more covered chronic health conditions that are expected to last for at least 12 months or until the death of the patient.

Under CCM, the patient's care team can bill for time spent managing patients' conditions, usually via services provided outside of a typical office visit. These activities can include things like formulating a comprehensive care plan, interactive remote communication and virtual care management, medication management, and coordination of care between providers.

Since the provision of CCM falls under Medicare Part B, both original Medicare and Medicare Advantage plans reimburse practitioners when CCM services are provided to eligible beneficiaries. Other requirements must be met to code, bill, and get paid for CCM. Learn about these rules and more in this Chronic Care Management Coding and Billing Guide.

What is a CCM-Eligible Chronic Condition?

As stated, chronic health conditions that are expected to last for at least 12 months or the lifetime of the patient can typically qualify a patient for chronic care management — if the patient is managing two or more diseases. Importantly, Medicare criteria must be satisfied. There is no set list of what conditions qualify under the criteria, but some common examples include:

Overview of Non-Complex and Complex CCM

While we will take a deeper dive into coding and billing for chronic care management later in this guide, understanding some coding and billing fundamentals can help one better understand the concept of CCM. The chronic care management service period is one calendar month. This means that practitioners may choose to submit a claim at the conclusion of the service period or after completing the minimum required service time.

Let's examine the basic (i.e., "non-complex") chronic care management codes: CPT 99490 and CPT 99491. Both require that the enrolled patient receiving services has two or more chronic conditions that are expected to last at least 12 months or until death; the chronic condition must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and a comprehensive care plan must be established, implemented, revised, or monitored. Finally, patients must provide explicit consent to enroll them in a CCM program.

When Medicare created the CCM program, the maximum time allotment eligible for reimbursement was limited. To encourage practitioner participation in CCM, and in response to requests of fairer compensation, time allotments were expanded in 2020 and can be billed with other CCM codes. Complex CCM is for patients with two or more qualifying conditions who require more clinical staff and physician time. Complex CCM is billed under CPT 99487 and CPT 99489.

It's important to note that while physicians, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants may all bill for CCM services, only a single practitioner may receive reimbursement per patient for CCM services for a given calendar month. Additionally, this practitioner must only report either non-complex or complex CCM for a given patient for the month.

The 2022 Physician Fee Schedule final rule delivered a significant increase in reimbursement for some chronic disease management services and finalized the addition of new CCM CPT codes. To learn more about the substantial changes to CCM, watch this webinar, which outlines the final rule's most significant developments related to care management and telehealth.

To understand more about the evolution of CCM and its coverage, let's review the current landscape through a historical lens.

CMS Throws Its Weight — and Wallet — Behind Chronic Care Management

A close read of the 2022 Medicare Physician Fee Schedule proposed and final rules show that CMS is increasingly demonstrating support for chronic care management. This evolution can be seen in the agency's willingness to accept the RVS Update Committee (RUC) recommended update values for 10 codes in the chronic care management family. Though not uncharacteristic for a rule, the justification includes language rarely used by CMS.

The agency stated that it was proposing to boost reimbursement because doing so would be:

Consistent with our goals of ensuring continued and consistent access to these crucial care management services and acknowledges our longstanding concern about undervaluation of care management under the physician fee schedule.

Such language is a clear indicator of the agency's support for CCM.

What's also noteworthy is that physician fee schedule rules are extensively reviewed and dissected by many committees, so there were many opportunities for this language to be removed. Since it was left in the proposed rule, it's safe to say that CMS recommending significant increases in payment for these services indicates that CCM has gained traction as a long-term care management strategy.

The final payment update, which echoed what was proposed, significantly increased reimbursement for the chronic care management CPT codes.

Growing Support for Chronic Care Management

The increase in reimbursement is just one way CMS has demonstrated its support for chronic condition management in recent years. The 2022 proposed rule identified several ways CMS has strived to support CCM in the past, including the 2014 ruling to finalize a unique payable HCPCS code for CCM, HCPCS GXXX1, and the 2015 adoption of separate payment for CCM services under CPT 99490.

CMS has continued to build on support for CCM reimbursement over the years in the following ways:

1. For 2017, CMS adopted complex chronic care management (CCCM) CPT codes 99487 and 99489.
2. In the 2019 Physician Fee Schedule final rule, CMS adopted new CCM CPT code 99491. This code reimburses physicians for performing 30 minutes of CCM care a month.
3. In the 2020 final rule, CMS established payment for an add-on code to CPT code 99490 by creating HCPCS code G2058. CMS also created two new HCPCS G codes: G2064 and G2065.
4. In the 2021 final rule, CMS finalized a replacement code for HCPCS code G2058: CPT 99439.

This brings us to 2022, for which CMS added coverage for the following five new CPT codes: CPT 99437, CPT 99424, CPT 99425, CPT 99426, and CPT 99427. Read more about what these codes encompass and other key takeaways from the 2022 Physician Fee Schedule (PFS) final rule here in a column authored by Prevounce Co-Founder Daniel Tashnek for Physicians Practice. With the final rule solidifying the reimbursement increase, CCM has become one of the most lucrative — and, one could argue, clinically beneficial — Medicare programs. To understand more about how practitioners are implementing CCM, let's look at one of the most common co-existing chronic diseases that qualify many patients for a CCM program.

The federal government has been increasingly supportive of care management programs. However, it is also more closely scrutinizing chronic care management reimbursement. It's important to ensure that you appropriately and consistently follow the rules of CCM codes and CCM billing. Expect more auditing to investigate causes of overpayment associated with incorrect billing of the service (more about this later in the chapter).

Rules for CPT 99490 and the Other Chronic Care Management Codes

Let's explore the most common and frequently used chronic care management CPT codes.

CPT 99490 and CPT 99491: Initial CCM Codes

We start our discussion about chronic care management coding and billing with the basic chronic care management CPT code, introduced in 2015, and its sister CPT code, which became effective in 2019. Together, these two CCM codes are sometimes referred to as the non-complex CCM codes.

CPT 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare 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 99490 assumes 15 minutes of work by the billing practitioner each month.

CPT 99491 Chronic care management services, provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified health care professional time, 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

Difference Between CPT 99490 and CPT 99491

The between CPT 99490 and CPT 99491 is subtle but significant. Under CPT 99490, clinical staff supervised by a physician or other qualified healthcare professional can perform CCM for billing purposes. CPT 99491, on the other hand, compensates physicians or other qualified healthcare professionals for time spent on CCM-related care and requires them to provide such care personally. CPT 99491 also requires a minimum of 30 minutes a month of CCM versus the 20 minutes required as per CPT 99490.

CPT 99439 and CPT 99437: CCM Add-On Codes

These are two CCM add-on codes: CPT 99439, which replaced HCPCS code G2058 in 2021, and CPT 99437, which was added for 2022 in the 2022 Medicare Physician fee schedule final rule.

CPT 99439 Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.

When to Report CPT 99439

CMS established payment for HCPCS code G2058 in its 2020 physician fee schedule final rule and then decided one year later to replace G2058 with CPT 99439. This code can be reported no more than twice per calendar month with CPT 99490 to capture additional care that exceeded the established 20-minute time allotments.

CPT 99437 Chronic care management services each additional 30 minutes by a physician or other qualified health care professional, per calendar month.

When to Report CPT 99437

As an add-on code for CPT 99491, it should only be billed for time spent beyond the initial 30 minutes spent providing services under 99491.

CPT 99487: Initial Complex CCM Code

Introduced in 2017 when the CCM benefit was expanded, this is a more complex CCM code. As we define in our glossary and noted earlier in this guide, complex CCM is intended for those patients with "two or more qualifying conditions who require more clinical staff and physician time" than non-complex CCM. In other words, these are patients who must also require moderate- to high-complexity medical decision-making. Let's look at the main CCM code.

 CPT 99487  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
• 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month

CPT 99489: Complex CCM Add-On Code

Now let's look at the add-on code to CPT 99487.

 CPT 99489  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).

When to Report CPT 99489

As the end of the description for CPT 99489 suggests, this code should not be listed on its own. Rather, report in conjunction with CPT 99487 when a patient requires an additional 30 minutes of care in the month. This comes on top of the 60 minutes already covered under CPT 99487.

Table: CY 2022 Chronic Care Management CPT Codes

Other Relevant Care Management Codes

In addition to these chronic care management codes, there are complementary services that are often billed with CCM by organizations that have developed a comprehensive care management program. Three examples are remote physiological monitoring (sometimes referred to as remote patient monitoring or RPM), behavioral health integration (BHI) care management services, and, less frequently, principal care management (PCM). Read more about these codes here or reference this helpful CMS resource. You can also learn more by reading this Medical Economics column written by Prevounce's Daniel Tashnek.

OIG Audit Reveals Chronic Care Management Overpayments

In mid-2021, the federal Office of Inspector General (OIG) conducted an audit covering nearly 8 million claims submitted by physicians and more than 240,000 claims submitted by hospitals for non-complex and complex chronic care management services provided in 2017 and 2018.

The results of this audit have short- and long-term implications for providers of CCM services as well as software vendors. Here are the most important things to understand about the audit and its consequences:

1. Why OIG performed the CCM audit — The agency specifically focused on whether payments made by the Centers for Medicare & Medicaid Service (CMS) for the two types of chronic care management services — non-complex and complex — during 2017 and 2018 complied with federal requirements. As OIG notes, "CCM services are a relatively new category of Medicare-covered services and are at higher risk for overpayments." This audit expands on the findings of a previous audit that found CMS lacked sufficient controls to effectively ensure Medicare payments for non-complex CCM services during 2015 and 2016 complied with federal requirements.
2. What the latest chronic care management audit found — The audit determined that there were nearly $2 million in overpayments associated with about 50,000 claims for non-complex and complex chronic care management services rendered during 2017 and 2018. From these claims, beneficiaries' cost sharing totaled up to about $541,000. According to OIG, the overpayment errors were attributed to CMS lacking claim system edits to prevent and detect overpayments.
3. What OIG recommended — Among several recommendations from the agency, these are some of the standouts:
• Direct Medicare contractors to recover the overpayments within the reopening period.
• Instruct providers to refund up to ~$541,000 which beneficiaries were required to pay.
• Notify appropriate providers to exercise reasonable diligence in identifying, reporting, and returning overpayments in accordance with the 60-day rule. The 60-day rule, created by the Affordable Care Act, requires providers to use reasonable diligence to identify overpayments via proactive compliance activities to monitor overpayments and investigate potential overpayments in a timely manner.
• Implement claim system edits to prevent and detect future overpayments for chronic care management services.

Considering Medicare's plans to support the growth of CCM, the audit's results suggest that CMS will be stepping up its oversight of the chronic care management program. What does this mean for practitioners? You'll need to step up your oversight as well and better ensure you are coding and billing properly — or face potential violation penalties. Keeping your CCM program compliant is not difficult, but it requires you to be mindful of the requirements when you set up your clinical and administrative workflows. Choosing a CCM software provider that makes compliance a top priority is extra insurance during periods of increased scrutiny and change.

Conclusion: Why the Time Is Now for Chronic Care Management

Chronic care management provides patients ongoing health and wellness support, greater access to appropriate medical resources and care team members, and a reduced need for emergency care. Meanwhile, practitioners experience improved care coordination, better patient satisfaction and engagement, and an opportunity to boost revenue. It's clear that CMS has affirmed support for CCM as a long-term patient care and coverage strategy by expanding reimbursements. In fact, there may never be a better time to add or grow a chronic care management program.

The bottom line: Chronic care management provides streamlined wraparound care for patients — and it's also good for business. So how does your organization take advantage of this growing opportunity?

An effective CCM program requires practice managers, practitioners, and clinical staff to work together to identify and enroll eligible beneficiaries and then establish processes that work well for everyone. If you are considering adding a CCM program or growing an existing program, you may also want to investigate launching other care management programs, such as remote patient monitoring and behavioral health integration.

With many complex moving pieces to juggle, you may find launching a CCM program can be difficult. But it doesn't have to be.

Prevounce has taken the lead to create user-friendly solutions that streamline the provision of chronic care management services, and we can help you build the components of your CCM program and navigate the challenges you will encounter along the way. With the right CCM software and vendor to support your efforts, you can keep the focus on delivering patient care and expanding your patient base. If you'd like to learn more about how we are helping organizations nationwide deliver CCM services, reinforce compliance, and safeguard security, book a meeting here.

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