Chronic Care Management billing has been on the mind of many of our clients.  

The Centers for Medicare & Medicaid Services (CMS) acknowledge that care management services play a pivotal role in primary healthcare, especially for individuals with chronic conditions.

This guide is designed to provide clear explanations on the necessary criteria and the billing process for providing the most frequently utilized care management services covered by Medicare.

The majority of chronic care management (CCM) services are typically invoiced according to the original criteria and definitions set forth in CPT code 99490.  This can be broken down into categories:

  • Patient Eligibility
  • Practice Requirements
  • Monthly Billing Conditions

Patient Eligibility

Patients must meet certain criteria to be eligible for participation in a chronic care management program.

It is mandatory for the patient to provide informed consent, either verbally or in writing, and this consent must be duly recorded in the patient’s medical file.

They must be informed of:

  • The CCM Program
  • Any possible cost sharing.
  • The fact that they can withdraw from the CCM program at any time.

They must also have multiple (2 or more) conditions that are classified as chronic conditions.

Some common chronic conditions that qualify are:

  • Arthritis
  • Depression
  • Diabetes
  • High Cholesterol
  • Hypertension

Patients must also have had an initiating visit withing the last year. (AWV or E/M encounter)

Practice Requirements

Your practice must also meet specific requirements for chronic care management billing.

Your practice must be using a certified EHR like the PacEHR™ electronic health record.

Monthly Billing Conditions

In order to bill for CCM each month, you must meet or exceed the following requirements:

  • A minimum of 20 minutes of time by clinical staff, under the guidance of a physician or a non-physician healthcare provider, is dedicated to managing the patient’s health and chronic conditions.
  • A detailed CCM care plan needs to be formulated, executed, or supervised.

Chronic Care Management Coding

  • CPT 99490: Billable after the first 20 minutes of CCM provided by clinical staff under supervision of the provider.  Reimbursement rate: ~$65 per instance.
  • CPT 99439 (formerly HCPCS G2058): Billable for each additional 20 minutes after 99490, up to a maximum of two times. Reimbursement rate: ~$50 per instance.

In addition, patients might also qualify for the BHI Programs:

Behavioral Health Integration (BHI)

  • To bill for BHI the patient must have a behavioral health conditional.
  • Progress must be tracked via a monthly validated assessment.
    • This can be a telehealth option.
  • 20 minutes is also required here and the validated assessment counts towards the time.
  • BHI is capped at 20 minutes.
  • Can be billed for the same patient in a CCM program during the month.

Behavioral Health Integration Coding

  • CPT 99484: First 20 minutes of BHI provided by clinical staff under supervision of the provider. Reimbursement rate: ~$43.

In conclusion, mastering the intricacies of Chronic Care Management Billing is essential for healthcare practices aiming to provide optimal care for patients with chronic conditions while ensuring appropriate reimbursement.

Understanding the eligibility criteria for patients, the specific practice requirements, and the detailed coding process, including CPT 99490 and CPT 99439, is vital for efficient billing.

Additionally, recognizing the potential for Behavioral Health Integration and its respective billing codes further broadens the scope of care that can be offered.

Staying informed and compliant with these guidelines not only facilitates smoother billing processes but also enhances the quality of care provided to patients.

For practices looking to streamline their Chronic Care Management billing, exploring advanced tools like the PacEHR™ electronic health record and its new CCM dashboard could prove invaluable.

Remember, effective Chronic Care Management Billing isn’t just about financial reimbursement—it’s a crucial component in delivering comprehensive, continuous care for those who need it most.

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