Chronic care management (CCM) services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. The Centers for Medicare & Medicaid Services (CMS) recognizes that CCM services include critical components of primary care services that promote better health and reduce overall health care costs. Lara Health platform supports CCM as one of the modules. Learn how chronic care management works.

1. Many Medicare beneficiaries qualify due to the wide description of a chronic condition

Patients with two or more chronic conditions qualify and CMS provided a wide interpretation of a chronic condition, making it applicable for many older patients. Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are eligible for CCM services. Examples of chronic conditions include, but are not limited to, the following:

• Alzheimer’s disease and related dementia 
• Arthritis (osteoarthritis and rheumatoid) 
• Asthma 
• Atrial fibrillation 
• Autism spectrum disorders 
• Cancer 
• Cardiovascular Disease 
• Chronic Obstructive Pulmonary Disease 
• Depression 
• Diabetes 
• Hypertension 
• Infectious diseases such as HIV/AIDS

2. There are 5 dedicated CCM codes and many complementary CPT codes to reimburse related services The five CPT codes used to report CCM services are:

• CPT code 99490 - non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability.
• CPT code 99439 - each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified health care professional (billed in conjunction with CPT code 99490)
• CPT code - 99487 complex CCM is a 60-minute timed service provided by clinical staff to substantially revise or establish a comprehensive care plan that involves moderate- to high-complexity medical decision making
• CPT code 99489 is each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualified healthcare professional (report in conjunction with CPT code 99487; cannot be billed with CPT code 99490)
• CPT code 99491 - CCM services provided personally by a physician or other qualified healthcare professional for at least 30 minutes.

3. Only one physician can bill for CCM

Chronic care management services can be performed by physicians looking after patients who benefit however, it’s most suitable for the primary care providers to take on this service. It’s important to understand that only one provider can bill for this service so a patient in care of more than one PCP or those with a specialist involved have the right to choose. The CCM service is not within the scope of practice of limited-license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.

4. The basic CCM services are usually performed by all primary care providers already, but you need to enroll the patient into a CCM program to be reimbursed

Most primary care providers already do services that fall under chronic care management and so adding a CCM service simply means they are now allowed to be reimbursed for it. Covered services include, but are not limited to:

• Management of chronic conditions
• Management of referrals to other providers
• Management of prescriptions
• Ongoing review of patient status

A lot of the ongoing care is performed by the clinical staff and a well designed program makes it easy for them to deliver a high quality of patient care.

5. Chronic care management ongoing services are performed by clinical staff, not physician

The CCM codes describing clinical staff activities (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required

6. CCM program is an ongoing program with monthly patient check-ins and reimbursements. The basic requirements include:

• Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
• Patient consent (verbal or signed)
• Personalized care plan at initiation, with a copy provided to patient
• 24/7 patient access to a member of the care team for urgent needs
• Enhanced non-face-to-face communication between patient and care team
• Management of care transitions
• At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by physician or other qualified health care professional
• CCM services provided by a physician or other qualified healthcare professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management activities

Lara Health includes a comprehensive CCM module built into the platform. Schedule a demo to see how easy it is to add CCM and other services into your practice (link)

7. Complex CCM service and CPT codes make chronic care management beneficial to the patient and financially significant to the practice

Complex CCM (CPT code 99487) shares common required service elements with CCM, but has different requirements for the complexity of medical decision making involved (which is moderate to high complexity) and the amount of time clinical staff provides (at least 60 minutes).

8. Enrolling patients into chronic care management program is easy, just get a verbal consent during the patient’s visit

For new patients or patients not seen within 1 year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an annual wellness visit or initial preventive physical exam, or other face-to-face visit with the billing practitioner). This initiating visit is not part of the CCM service and is billed separately. Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services). G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.

9. CCM program starts with a comprehensive care plan

When a patient is enrolled into a chronic care management program, practitioner creates a comprehensive care plan for all health issues. It typically includes, but is not limited to, the following elements: 

• Problem list 
• Expected outcome and prognosis 
• Measurable treatment goals 
• Symptom management 
• Planned interventions and identification of the individuals responsible for each intervention 
• Medication management 
• Community/social services ordered 
• A description of how services of agencies and specialists outside the practice are directed/coordinated 
• Schedule for periodic review and, when applicable, revision of the care plan

10.  Chronic care management is complementary to remote patient monitoring and creates recurring revenue while allowing physicians to delegate some of the care to their support staff

Lara Health’s multi-care optimization platform stacks the most impactful care models and digital tools onto one integrated platform, making it easy for practitioners to deliver the best possible care to their patients in the most efficient way. Using Lara Health means admin work is reduced and reimbursements simplified so doctors can reclaim their time and their clinical teams work more efficiently. 

Source: AAFP and CMS