Chronic Care Management (CCM) Services

Chronic Care Management (CCM) is a Medicare program that provides reimbursement to healthcare providers for coordinating care for Medicare beneficiaries with two or more chronic conditions. The goal of CCM is to improve patient outcomes, reduce hospitalizations, and enhance care coordination between providers

Chronic Care Management (CCM) refers to a coordinated healthcare strategy designed for patients with two or more chronic conditions expected to last at least 12 months. It focuses on improving health outcomes, enhancing quality of life, and reducing healthcare costs through comprehensive care and support.

Principal Care Management (PCM) in the medical context refers to a specialized approach for managing patients with a single high-risk chronic condition. This model is designed to provide focused care coordination and treatment for individuals whose conditions require ongoing monitoring and frequent adjustments to their care plans.

Chronic Care Management (CCM) and Principal Care Management (PCM) are both healthcare services aimed at supporting patients with chronic conditions, but they differ in focus. CCM is designed for patients with two or more chronic conditions expected to last at least 12 months, emphasizing comprehensive care coordination and management strategies to improve health outcomes. In contrast, PCM targets patients with a single chronic condition requiring intensive management, focusing on that one high-risk diagnosis. Both services involve care coordination and billing under specific Medicare codes, but they cater to different patient needs within the healthcare system.

CCM stands for Chronic Care Management. This is a structured approach designed to coordinate care for patients with two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. The primary goals of CCM are to improve patient outcomes, enhance the quality of care, and reduce hospitalizations by providing comprehensive care coordination.

Medicare provides significant reimbursement for non-face-to-face chronic care management, with codes ranging from $62-$92 per month. Proper utilization of these codes can generate additional revenue for practices while improving care coordination and outcomes for patients with multiple chronic conditions.

CPT code 99490 is used to bill for Chronic Care Management (CCM) services provided by clinical staff under the direction of a physician or other qualified healthcare professional. Here are the key details about CPT 99490:

Requirements

• At least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional per calendar month
• Establishment, implementation, revision, or monitoring of a comprehensive care plan
• Coordination of care with other providers and agencies
• Medication management
• Patient education and self-management support

Reimbursement

• The national average Medicare reimbursement rate for CPT 99490 in 2023 is $62.69 per patient per month
• Actual reimbursement varies by geographic region and may be higher for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

Billing Guidelines

• Can only be billed once per patient per calendar month
• Cannot be billed in the same month as certain other care management codes like Transitional Care Management (99495-99496) or Home Health Care Supervision (G0181)
• Requires an initiating visit with the billing provider within the prior 12 months
• The patient must provide verbal or written consent to receive CCM services

Eligible Providers

• Physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical nurse specialists
• Must be legally authorized to provide CCM services in their state

The difference between CPT codes 99487 and 99490 lies primarily in the complexity of care, the duration of service, and the level of medical decision-making involved.

CPT Code 99487

• Purpose: This code is designated for complex chronic care management (CCM).
• Time Requirement: 60 minutes of clinical staff time directed by a physician or qualified healthcare professional (QHP) in a calendar month is required.
• Complexity: It is used for patients with two or more chronic conditions that necessitate moderate to high complexity medical decision-making. This typically involves substantial revisions to the comprehensive care plan due to the complexity of the patient’s condition
• Reimbursement: The reimbursement rate for this code is generally higher, around $134.27 per month

CPT Code 99490

• Purpose: This code is used for non-complex chronic care management.
• Time Requirement: It requires only 20 minutes of clinical staff time per month under the direction of a physician or QHP.
• Complexity: It applies to patients with two or more chronic conditions expected to last at least 12 months, but these conditions do not require the same level of decision-making complexity as those billed under 99487
• Reimbursement: The reimbursement for this code is lower, averaging about $64.02 per month

Whether you’re a primary care office or a specialty provider, our Vital Health Services care team is here to support you in closing gaps in patient care. Addressing these gaps helps improve your MIPS scores, Star Ratings, and ACO compliance, which can lead to better reimbursements. Additionally, your practice can create a steady revenue stream by billing for Chronic Care Management services, using CPT codes 99490 or G0511

Medicare patients with multiple chronic conditions are at high risk for serious health issues. With Chronic Care Management (CCM), you can offer these patients around-the-clock support and personalized care plans. By integrating CCM with the care you already provide, you can help lower their chances of emergency room visits and enhance their overall quality of life.

Healthcare providers can offer Chronic Care Management (CCM) independently, but it is more operationally complex than one might anticipate. The technology and resources needed to deliver a comprehensive and compliant service are extensive but essential. Outsourcing can provide access to these resources along with a dedicated care team available 24/7 to support your program.

Our team identifies CCM-eligible patients from your practice’s EMR and contacts them to obtain their consent to participate in the program. After enrollment, we communicate with the patients every month to engage in care coordination activities aimed at improving their health outcomes. Additionally, we provide them access to our 24/7 nurse line. All activities are documented in a comprehensive care plan, which is then shared with the provider through the EMR.