Chronic Care Management

Many patients have chronic health conditions. In fact, of the 70,000 ICD-10 diagnosis codes in existence, there are close to 10,000 codes for chronic conditions. Improving the management of chronic care conditions is important not only for the sake of individual patients, but also to physicians, health systems and insurers. Chronic conditions often require more time of physicians and their teams between visits. Because of this, there are now CPT codes for Chronic Care Management. Additionally, the Centers for Medicare and Medicaid Services (CMS) created strategies to “weight” various complex health conditions by assigning hierarchical categories, and this can affect reimbursement in several ways, as we discuss later. 

The Chronic Care Management (CCM) Codes were introduced in 2015 to allow for billing of non-face-to-face care provided by clinical staff. In order to qualify, the patient must have two or more chronic conditions which are expected to last at least 12 months (or until death), and these conditions must place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline. CMS estimates that 2/3 of Medicare-eligible patients would qualify for CCM services. Insurance payors are increasingly paying for these services because they tend to reduce ED visits and hospitalizations.

Documentation of Care Plan

These codes are fairly straightforward, but you still need to know a few details to make sure all requirements are met. The foundation for CCM services is having a care plan in place. “Care Planning” is not vocabulary that typically stems from the physician side, but should be thought of as merely a “plan of care.” It is generally a little more extensive than an office note, but should be succinct enough for patients, as well as clinical staff and colleagues, to understand the conditions, the goals of care, treatment/intervention plans, and rationale. Such a summary would be good for any patient, regardless of CCM billing.

As adapted from the CPT Professional codebook, a typical plan of care isn't limited to, but may include:

●      Problem list

●      Expected outcome and prognosis

●      Measurable treatment goals

●      Cognitive assessment

●      Functional assessment

●      Symptom management

●      Planned interventions

●      Medical Management

●      Environmental evaluation

●      Caregiver assessment

●      Interaction and coordination with outside resources and other health care professionals and others, as necessary

●      Summary of advance directives

Rather than a strict set of requirements, these elements are intended to be a guide for creating a meaningful plan of care, so should be addressed only as appropriate for the individual. This plan should include specific and achievable goals for each condition and be relevant to the patient’s well-being and lifestyle. When possible, the treatment goals should also be measurable and time bound. The plan should be updated periodically based on status or goal changes. The entire care plan should be reviewed at least annually and an electronic and/or printed plan of care must be documented and shared with the patient and/or caregiver.

CCM and Complex CCM Codes

Once a care plan is in place, it must be implemented and supported. Clinical staff and physicians may work on prescriptions, prior authorizations, review medical records and quality metric work, schedule appointments, and respond to patient-related messages.

NOTE: This work must not include work that is otherwise already included in other services being reimbursed, e.g., after a routine office visit that includes labs being drawn—the call related to conveying those lab results couldn't be counted toward CCM time. However, if the work is unrelated to that specific office visit, then counting it toward CCM would be appropriate.

CCM codes are submitted on a monthly basis, and are based on the time spent each month caring for the patient outside of office visits, or “non-face-to-face time.” Coding also depends on whether a physician alone provided the time, or clinical staff (with or without a physician’s time). Note: “physician” also includes other qualified health professionals (QHPs) who can bill, such as PAs or APRNs, but for this document, we just use the term physician.

The clinical staff CCM codes are based on increments of 20 minutes of work on behalf of patients; up to 60 minutes for regular CCM, or 30 minute increments (beyond the first 60 minutes) for Complex CCM. The base code is 99490 for 20 minutes of clinical staff time; for each additional 20 minutes, the code is 99439. 

Note: You must reach the time allotments in order to bill, not round up, i.e., if you provide only 18 minutes, you can't bill 99490. Documentation of time spent by clinical staff (and the physician) is crucial. Often this is done in a separate note or message that is “added to” each months documentation. 

There are also codes that capture physician-only time, starting at 30 minutes time, and increasing by 30-minute intervals. The base code for physician-only time is 99491, starting at 30 minutes of time up to 60 minutes, and the 99437 code is used after 60 minutes. If the physician’s time falls short of the time requirements, it may be used to count toward the clinical staff time codes. Only one physician may bill for CCM codes in a particular month and may not bill for both staff and physician codes in the same month. The physician/QHP codes may be particularly helpful to cover work time performing in-depth chart review or medication reconciliation that isn’t connected with billing for an office visit.

In some months, the collective time for both physician and staff may be insufficient to bill a CCM code; it isn’t a requirement to submit charges monthly—as patient’s needs vary, so do their medical services. Minutes from one month may not be “banked” for another.

In general the CCM codes are preferred over Complex CCM. For one thing, there are a few additional eligibility requirements. Next, while technically one could use either 99490 or 99487 for 60 minutes of care management, the RVUs are greater for the CCM codes.  The CCCM codes would typically be used when services exceed 90 minutes, which might be expected with a high intensity patient, such as fragile CHF.

These are the codes that may be used related to CCM and CCCM:

From a fiscal standpoint, these codes enable family physicians to lead and support the patient-centered medical home. For years, primary care offices have been providing all sorts of services between patient visits, i.e., medication refills, form completions, prior authorizations, family meetings, and much more—without compensation. While these activities are naturally delivered outside of the office visit, Care Management codes promote these activities through payment. 

These provider-based codes are a more recent addition to the code set. Most activities are fair game to count toward CCM time, as long as the work isn’t already captured through other submitted codes (i.e., an office visit). What a great way to do a deep chart review for a patient, review consultant notes, and perform a thorough medication reconciliation! These are all activities that simply can’t be adequately performed during an office visit.

CCM isn’t just a set of codes. Rather it’s a mindset requiring team and institutional embracement of a shift to a proactive and comprehensive approach to patient care. As family physicians, you are poised to lead these teams. And as you make the case to your teams (and employers), you must emphasize the role CCM plays in improved care outcomes, reducing health care costs, and improving patient and provider satisfaction.

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