Coding & Billing for Care Coordination
Approaches to funding a care coordinator may include:
- Utilization of care coordination codes
- Coding and billing for physician services related to care coordination (the links above include relevant information)
- Leveraging existing staff to identify skills and opportunities
- Creating partnerships with large organizations, such as hospital systems or insurance companies, that will support care coordination activities
- Seeking grants and foundation funding
Chronic Care Management Services
In 2015, Medicare began paying separately under the Medicare Physician
Fee Schedule (PFS) for Chronic Care Management services furnished to Medicare
patients with multiple chronic conditions. Then, recognizing that suboptimal
management of chronic conditions can lead to declines in health, significant
morbidity, or potential mortality, some of the language and regulations
regarding CCM codes were relaxed in 2016 to increase the amount of CCM Services
being performed.
Below is a list of the 3 CPT codes related to CCM, along with some
brief general guidelines for billing these services.
Chronic Care Management - CPT 99490 - for at least 20
minutes
“Chronic care management services, 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:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions place the patient at a significant risk of death, acute exacerbation/decompensation, or functional decline
- Comprehensive care plan established, implemented, revised, or monitored”
Example: During the month, a care coordinator spends time in care
plan monitoring for a patient with Asthma and ADHD that has already
consented to CCM. The care coordinator spends a total of 20 minutes of
non-face-to-face care management services following-up with family regarding
effectiveness of patients’ asthma controller medication after an
exacerbation and ER visit the previous month.
Coding: CPT 99490 (Chronic care management service, 20 minutes)
Complex Chronic Care Management (CPT codes 99487 and
99489)
CPT 99487 - for first 60 minutes
“Complex chronic care management services, with the following
required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
- Establishment or substantial revision of a comprehensive care plan
- Moderate or high complexity medical decision making
- 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month”
Example: “Office visit with an established 20-year-old female
patient with spastic quadriplegia due to cerebral palsy.” During this
regular chronic care visit the physician talks with the young adult and
parent about transition of care to adult provider. After the visit, “the
pediatrician and clinical staff devote an additional 60 minutes to
non-face-to-face care management services to prepare the transfer
letter, contact the young adult’s other specialists to coordinate the
transfer information, consult with the new adult doctor, and call the
young adult to review final plans for transfer, with the date for the
initial adult appointment.”
Coding after the visit: CPT 99487 (Complex, chronic care
management service, 60 minutes)
CPT 99489 – for additional time beyond 60
minutes
“Each additional 30 minutes of clinical staff time directed by
a physician or other qualified health care professional, per calendar
month (List separately in addition to code for primary
procedure)"
Example: "A week after a visit with an established 20-year-old
female patient with spastic quadriplegia due to cerebral palsy, but
within the same calendar month. The clinical staff devote an additional
30 minutes to non-face-to-face care management services to prepare the
transfer letter, contact the young adult’s other specialists to
coordinate the transfer information, consult with the new adult doctor,
and call the young adult to review final plans for transfer, with the
date for the initial adult appointment.”
Coding: CPT 99489 (Complex, chronic care management service,
additional 30 minutes)
General Guidelines
Patient Eligibility: The billing practitioner can bill either complex
or regular CCM in a calendar month, but not both.
Initiating Visit: If a patient hasn’t been seen in the prior 12
months, an initiating visit is required, and either verbal or written consent
needs to be obtained and listed in the EMR. If the patient has been seen in the
prior 12 months, an initiating visit isn’t required, but documented consent
still must be obtained.
Patient Consent: Advanced consent is required and must include the following:
- “The availability of CCM services and applicable cost-sharing
- That only one practitioner can furnish and be paid for CCM services during a calendar month
- The right to stop CCM services at any time.
Resources
Information & Support
For Professionals
Chronic Care Management Services - Fact Sheet (
554 KB)
DHHS/Centers for Medicare & Medicaid Services put together this extensive fact sheet on Chronic Care Management (CCM). It
provides background on payable CCM service codes,
identifies eligible practitioners and patients, and details the Medicare PFS billing requirements.
CMS Chronic Care Management Services Changes for 2017 ( 521 KB)
Chronic Care Management (CCM) services by a physician or non-physician practitioner and their clinical staff, per calendar
month, for patients with two or more chronic conditions expected to last at least 12 months.
2022 Coding and Payment Tip Sheet for Transition from Pediatric to Adult Health Care ( 509 KB)
Thirty-two page booklet of CPT coding options for the provision of transition-related services; from Got Transition and the
American Academy of Pediatrics.