Requirements for Chronic Care Management

Information may not be reliable

An arrangement of care must be documented and imparted to the patient and/or caregiver. It ought to be thorough, in light of a physical, mental, psychological, social, utilitarian, and environmental assessment and address all medical issues.  CCM services are management and support services provided by clinical staff under the guidance of a physician or other qualified healthcare provider to a patient living at home or in a home, domiciliary, rest home, or assisted living facility. The physician or other qualified health care professional oversees and/or supervises the management and / or coordination of the services required for all medical conditions, psychosocial needs, activities of daily living. 

 CPT 99490 for CCM services include, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following required elements:

Qualified health care professionals treating patients with 2 or more chronic conditions could be eligible to bill the code. However, only 1 physician may report these services for a given patient in a given month.

There is no defined list of diagnosis codes that meet the requirements of CCM. Rather, what is required is that the chronic conditions place the patient at significant risk of death, acute exacerbation/de compensation and that management requires a care plan.

Comprehensive care plan established, implemented, revised or monitored.

To reimburse separately for non-face-to-face care coordination services Medicare has designed an unique physician fee schedule for multiple chronic conditions. CPT 99490 is the much awaited code for treating patients with several chronic conditions and has also been included in Centers for Medicare and Medicaid Services PFS in 2015 onward.

Application of electronic care plan

Practices must meet the necessary care plan access requirement through the use of remote access to an EHR or portal, for example, web-based access to a care management application, use of secure messaging, or web-based access to a health information exchange service (HIE) that captures and maintains care plan information.

Electronic Technology

Practices are not required to use a specific electronic technology. Electronic care plan needs to be accessible at all times to the clinicians within the practice and also with those providing CCM services outside of normal business hours. The word “within the practice” means any clinician furnishing CCM services whose minutes count toward a given practice's time requirement for reporting the CCM billing code.

Billing CCM with E/M and Patient Consent

An evaluation and management (E/M) visit may be billed at the same time as the CCM code, however, any clinical staff time on a day when the physician reports an E/M service may not be counted toward the care management service code. E/M services may be reported independently by the same physician during the same calendar month.

CCM services may only be reported if the patient/caregiver has given consent. A requirement of the service is knowledge and recognition by the patient that the physician or qualified health care professional will perform CCM services on the patient's behalf. Documentation of patient consent is pivotal in providing the service.  The informed agreement process need occur only once at the start of furnishing the service,  and it needs to be repeated only if the patient opts to change the practitioner who is delivering the services. The patient will be responsible for paying and the practice will be required to collect the 20% co-insurance and any applicable deductibles, unless the patient has separate supplemental coverage.