Chronic care management (CCM) is a billable Medicare service that’s meant to improve the lives of both patients and physicians.
You qualify for CCM services if you have Medicare and two or more chronic conditions. The conditions need to last anywhere from 12 months to the rest of your life for you to be eligible.
The goal of CCM services is to provide coverage for the many non-face-to-face interactions that are needed to optimally manage multiple chronic conditions.
What Is a Chronic Condition?
A chronic condition is a long-term medical disease or disorder. These conditions aren’t easily cured and require in-depth care. This can be complicated if you have multiple chronic conditions to manage.
You need to be diagnosed with at least two chronic conditions to qualify for CCM. An example chronic care management diagnosis list includes:
- Alzheimer’s disease
- Rheumatoid arthritis
- Autism spectrum disorders
- Cardiovascular disease
- HIV and AIDS
This list is not exhaustive. There are many additional conditions that qualify you for CCM. Based on your condition, your doctor or medical staff should know whether or not you qualify for CCM services.
What Are Chronic Care Management Services?
Chronic care management services are a specific Medicare Part B benefit. They’re intended to include all of the not-in-person work behind the medical decisions in complex chronic cases.
The overall goal of CCM is to promote your health while reducing costs. If you qualify for CCM services, then your medical team will be able to bill Medicare for a wide range of additional tasks that benefit you. One of the most reassuring benefits is that you should be able to reach a physician or other member of your medical team 24 hours a day, seven days a week to discuss any urgent needs.
Other CCM services can include:
- Coordinating information and referrals between your entire medical team
- Refilling prescriptions
- Symptom management
- Patient health education
- Preventative health counseling
- Community resource referrals
- Interventions to reduce risk factors for falls
- Coordinating social support services
CCM services can either be simple or complex. Complex services are billed differently. A service counts as complex if, for example, it involves difficult medical decisions. Only one of your providers can bill Medicare for CCM services during any given month.
What Is an Initial Visit?
You cannot begin receiving CCM services until you’ve had an initial visit. This must occur face-to-face, but you don’t need to make a special appointment just to discuss CCM services. An initial visit can occur as part of an already-scheduled service, including:
- Annual wellness visits
- Initial preventative physicals
- Transitional care visits
- Any other scheduled visit to your primary health care provider
For your in-person visit to count as an initial visit, your doctor must discuss CCM services with you. Your doctor should get written or verbal consent to include you in CCM services because you’re responsible for part of the bill.
It’s important to note that a doctor only needs a patient's consent one time to bill for these services.
You can stop CCM services whenever you want to; you just have to talk to your medical team.
What Does a Comprehensive Care Plan Include?
Following your initial visit, your doctor or health care provider should draw up a comprehensive care plan that’s specifically focused on you and your needs. This process could require an additional in-person visit to complete.
Details that could be part of your care plan include:
- Expected outcomes
- Measurable goals to work toward during treatment
- Assessments of your current physical and mental states
- Medication management plans
- Environmental evaluations
- Caregiver evaluations
- Details for coordinating your entire medical team
- A requirement to periodically review your plan
Who Can Provide Chronic Care Management?
Since CCM is a Medicare billable service, only qualified providers can include CCM services in their monthly billing. In order to bill for these services, Medicare requires that all activities are supervised by a:
- Clinical nurse specialist (CNS)
- Nurse practitioner (NP)
- Physician assistant
- Certified nurse-midwife
This means that you can’t bill Medicare for CCM if your organization only employs registered nurses. However, your organization could find a qualified supervisor while still serving as the medical provider.
Supervisors do not need to be physically present when a CCM service is being provided, but it must be done under their general instruction and guidance.
It’s important to note that whoever is providing the service must be a member of the clinical care team, not on the administrative staff.
States may have their own regulations about who can and cannot provide CCM services. These are not always identical to Medicare’s requirements.
Will You Have to Pay For Chronic Care Management?
Since chronic care management services are a Medicare Part B benefit, only 80 percent of these services are covered by Medicare. This means that you’re responsible for 20 percent of the total CCM bill.
People with Medigap or who are covered by both Medicare and Medicaid will likely not have to pay any copay. Instead, your medical team should charge the additional 20 percent to the agency that provides your added coverage.
What Are the Chronic Care Management Codes?
There are five codes that describe the ways that chronic care services are billed to Medicare.
These chronic care management codes include the CPT codes:
- 99490. This is the basic code for non-complex chronic care management provided for 20 minutes.
- 99439. This code should be used in conjunction with code 99490 to bill additional chunks of 20 minutes that are spent on non-complex chronic care management decisions by a member of the clinical staff.
- 99491. This is the only in-person code for CCM services. It should be used when the physician or clinical team member spends at least 30 minutes on these services with the beneficiary.
- 99487. This code is used for complex CCM decision-making. The services should take 60 minutes or less. This is used when creating or revising a medical care plan and other decisions that require moderate and high-complexity decision-making by your medical team.
- 99489. This code is used to bill each additional 30 minutes of complex CCM.
What Is the Difference Between Principal and Chronic Care Management?
Principal care management (PCM) is a newer Medicare service that began in 2020. It’s meant to fill in some of the gaps left by CCM.
This service is specifically for people who only have a single chronic condition but still need their medical team to provide complex and coordinated care. It also applies to someone with multiple chronic conditions whose medical team needs to focus on one high-risk diagnosis.
PCM is billed with different codes than CCM.