Rural programs often seek reimbursement opportunities to pay for care coordination services. Insurers may respond to care coordination codes differently, so it is important for rural programs to determine which codes are covered, by which insurers, how much money is offered, and how to use them properly. One reimbursement opportunity is to use Current Procedural Terminology (CPT) codes to bill insurers for care coordination services.
For transitional care management (TCM), complex chronic care coordination, and chronic care management (CCM), CMS provides specific guidelines for using these codes for care coordination.
99495 – Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge).
Transitional care management with high medical decision complexity (face-to-face visit within 7 days of discharge) – CPT Code 99496
CPT Code 99490: Chronic care management for a patient with multiple chronic conditions (at least 20 minutes spent with patient per month)
The CPT code for 99487 is Complex Chronic Care Management for a patient with multiple chronic conditions (60 minutes per month spent with the patient).
99489 – Each additional 30 minutes spent with a patient on complex chronic care management per month
Services for Chronic Care Management
As of 2015, Medicare is paying separately for Chronic Care Management services furnished to Medicare patients with multiple chronic conditions under the Medicare Physician Fee Schedule (PFS). Then, recognizing that suboptimal chronic condition management can lead to significant morbidity or mortality, some of the language and regulations regarding CCM codes were relaxed in 2016 to increase the amount of CCM services being performed.
Here are three CPT codes related to CCM, along with some general billing guidelines.
CPT 99490 – Chronic Care Management – at least 20 minutes
A physician or other qualified health care professional must direct at least 20 minutes of clinical staff time per calendar month to provide chronic care management services, which include the following components:
Two or more chronic conditions that are expected to last at least 12 months, or until the patient dies
In chronic conditions, there is a significant risk of death, acute exacerbation/decompensation, or functional decline.
Establishment, implementation, revision, or monitoring of a comprehensive care plan”.
During the month, a care coordinator monitors the care plan of a patient with asthma and ADHD who has already consented to CCM. After an exacerbation and ER visit the previous month, the care coordinator spends 20 minutes providing non-face-to-face care management services to the patients’ families to make sure asthma controller medication is effective.
- Code: CPT 99490 (Chronic care management service, 20 minutes)
- Managing complex chronic conditions (CPT codes 99487 and 99489)
- For the first 60 minutes, CPT 99487 is applicable
The following elements must be included in complex chronic care management services:
Chronic conditions expected to last at least 12 months, or until death. The patient is at risk of death, acute exacerbation/decompensation, or functional decline when suffering from chronic conditions. A comprehensive care plan should be established or substantially revised. Medical decision-making of moderate to high complexity. Per calendar month, 60 minutes of clinical staff time directed by a physician or other qualified health care professional.”
After the office visit with the established 20-year-old patient who has spastic quadriplegia caused by cerebral palsy, the physician and parent discussed transitioning care to an adult provider. The pediatrician and staff then spent extra time providing non-face-to-face care management services which included writing a transfer letter, speaking with other specialists to arrange for information transfers, speaking to the new doctor and calling the patient to explain final plans for the transition, including when their initial adult appointment would be.
CPT 99487 (Complex, chronic care management service, 60 minutes):
For additional time beyond 60 minutes, use 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 along with the primary procedure code)”
A week after seeing a 20-year-old female patient with spastic quadriplegia caused by cerebral palsy, the clinical staff spent an extra half hour conducting non-face-to-face care management services. This preparation included drafting a transfer letter, liaising with the patient’s other specialists for the necessary information, consulting the new adult physician and phoning the patient to explain the finalized plans for her transfer and scheduling her first appointment as an adult.
CPT 99489 (Complex chronic care management, additional 30 minutes)
