Page 1 of 15
Chronic Care Management Services
MLN909188 September 2022
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved.
Applicable FARS/HHSAR apply. CPT is a registered trademark of the American Medical Association. Fee schedules,
relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and
the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical
services. The AMA assumes no liability for data contained or not contained herein.
MLN BookletChronic Care Management Services
MLN909188 September 2022Page 2 of 15
Table of Contents
What’s Changed? ................................................................................................................................ 3
Chronic Care Management Service Elements: Highlights .............................................................. 4
Chronic Care Management Service Practitioners ............................................................................ 5
Supervision .......................................................................................................................................... 6
Patient Eligibility .................................................................................................................................. 6
Initiating Visit ....................................................................................................................................... 7
Patient Consent ................................................................................................................................... 7
Recording Patient Health Information ............................................................................................... 8
Comprehensive Care Plan .................................................................................................................. 8
Access to Care & Care Continuity ..................................................................................................... 8
Comprehensive Care Management.................................................................................................... 9
Manage Care Transitions
.................................................................................................................... 9
Concurrent Billing ............................................................................................................................... 9
Principal Care Management ............................................................................................................. 10
Chronic Care Management & Principal Care Management Codes ................................................... 10
Chronic Care Management & Medicare Demonstrations .............................................................. 12
Chronic Care Management Service Summary ................................................................................ 13
Resources .......................................................................................................................................... 15
MLN BookletChronic Care Management Services
MLN909188 September 2022Page 3 of 15
What’s Changed?
●
Beginning 2022, Rural Health Clinics (RHCs) and Federally Qualied Health Centers
(FQHCs) can bill Chronic Care Management (CCM) and Transitional Care Management
(TCM) services for the same patient during the same time period (page 9)
●
In 2021 we added 5 codes to report sta-provided Principal Care Management (PCM)
services under physician supervision (pages 10–11)
●
Beginning 2022 we replaced G2058 with 99439 (page 11)
You’ll nd substantive content updates in dark red font.
CPT only copyright 2021 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
MLN909188 September 2022Page 4 of 15
Note: Information in this
publication applies only to
the Medicare Fee-for-Service
Program (also known as
Original Medicare).
Together we can advance
health equity and help eliminate
health disparities for all minority
and underserved groups. Find
resources and more from the
CMS Oce of Minority Health:
●
Health Equity Technical
Assistance Program
●
Disparities Impact Statement
CMS recognizes Chronic Care Management (CCM) is a
critical primary care service that contributes to better patient
health and care.
This booklet provides background on payable CCM service
codes, names eligible billing practitioners and patients,
and details the Medicare Physician Fee Schedule (PFS)
billing requirements.
In 2014, we started paying for CCM services furnished to
patients with multiple chronic conditions under the PFS.
The Medicare Physician Fee Schedule Look-Up Tool has
code-specic payment information by geographic location.
Note: “You” refers to practitioners.
As the billing practitioner, you no longer need to oer
face-to-face CCM services to Rural Health Clinic (RHC) or
Federally Qualied Health Center (FQHC) patients because
CCM describes non-face-to-face services.
Chronic Care Management Service Elements: Highlights
CCM services are extensive, including:
●
Structured recording of patient health information
●
Keeping comprehensive electronic care plans
●
Managing care transitions and other care management services
●
Coordinating and sharing patient health information promptly within and outside the practice
CCM service elements apply to complex and non-complex CCM unless otherwise specied.
See Chronic Care Management Service Summary section for more information.
You’ll typically furnish CCM services outside face-to-face patient visits and focus on advanced primary
care characteristics like:
●
Continuous patient relationship with chosen care team member
●
Supporting patients with chronic diseases in achieving health goals
●
24/7 patient access to care and health information
●
Patient receiving preventive care
●
Patient and caregiver engagement
●
Prompt sharing and using patient health information
MLN BookletChronic Care Management Services
MLN909188 September 2022Page 5 of 15
Chronic Care Management Service Practitioners
These physicians and Non-Physician Practitioners (NPPs) may bill CCM services:
●
Certied Nurse Midwives (CNMs)
●
Clinical Nurse Specialists (CNSs)
●
Nurse Practitioners (NPs)
●
Physician Assistants (PAs)
Note: Primary care practitioners most often bill CCM services, but some specialty practitioners may
furnish and bill them as well. CCM services aren’t within the scope of practice of limited-
license physicians and practitioners like clinical psychologists, podiatrists, or dentists, but
CCM practitioners may refer or consult with these practitioners to coordinate and manage care.
CPT code 99491 — Time only the billing practitioner spends. Clinical sta time doesn’t count toward
the required reporting time threshold code.
CPT codes 99487, 99489, and 99490 — Time spent directly by clinical sta. Time spent by the billing
practitioner may also count toward the time threshold if not used to report 99491.
For CCM services the billing practitioner doesn’t personally furnish, the clinical sta furnish them under
direction of the billing practitioner on an incident to basis (as an integral part of services furnished
by the billing practitioner), subject to applicable state law, licensure, and scope of practice. Clinical
sta are employees or working under contract with the billing practitioner and we directly pay that
practitioner for CCM services.
CPT only copyright 2021 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
MLN909188 September 2022Page 6 of 15
Supervision
●
We assign CCM codes describing clinical sta activities (CPT 99487, 99489, and 99490) as general
supervision under the Medicare PFS
●
General supervision means when the billing practitioner doesn’t personally furnish the service, it’s
done under their overall direction and control
●
We don’t require the physician’s physical presence while service is furnished
Patient Eligibility
● Eligible CCM patients will have multiple (2 or more) chronic conditions expected to last at least 12
months or until the patient’s death and or that place them at significant risk of death, acute
exacerbation and or decompensation, or functional decline
● These services aren’t ty
pically face-to-face and allow eligible practitioners to bill at least 20 minutes
or more of care coordination services per month
● Billing practitioners may consider identifying patients who require CCM services using criteria
suggested in CPT guidance (like number of illnesses, number of medications, repeat admissions, or
emergency department visits) or the typical patient profile in the CPT prefatory language
● CCM services can also help reduce geographic and racial or ethnic health care disparities
Examples of chronic conditions include, but aren’t limited to:
● Alzheimer’s disease and related dementia
● Arthritis (osteoarthritis and rheumatoid)
● Asthma
● Atrial fibrillation
● Autism spectrum disorders
● Cancer
● Cardiovascular disease
● Chronic Obstructive Pulmonary Disease (COPD)
● Depression
● Diabetes
● Hypertension
● Infectious diseases like HIV and AIDS
CPT only copyright 2021 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
MLN909188 September 2022Page 7 of 15
Initiating Visit
●
Before CCM services can start, we require an initiating visit
for new patients or patients who the billing practitioner hasn’t
seen within 1 year
●
Initiating visit can occur during comprehensive face-to-face
Evaluation and Management (E/M) visit, Annual Wellness
Visit (AWV), or Initial Preventive Physical Exam (IPPE)
●
If practitioner doesn’t discuss CCM during an E/M visit, AWV,
or IPPE, it can’t count as the initiating visit
●
Face-to-face initiating visit isn’t part of CCM and can be
separately billed
Although patient cost
sharing applies to the CCM
service, some patients have
Supplemental Insurance
(Medigap) to help cover CCM
cost sharing. Also, CCM may
help avoid the need for more
costly services in the future
by proactively managing
patient health, rather than
only treating severe or acute
disease and illness.
Practitioners who personally furnish extensive assessment and
care planning outside the usual eort described by the initiating visit and CCM codes may also bill:
●
HCPCS code G0506 — Comprehensive assessment of and care planning by the physician or
other qualied health care practitioner for patients requiring CCM services (billed separately from
monthly care management services) (Add-on code, list separately in addition to primary service)
●
Billing practitioners can bill G0506 only once, as part of initiating visit
Patient Consent
Get the patient’s written or verbal consent for CCM services before you bill for them. This helps
ensure patients are engaged and aware of their cost sharing responsibilities. This also helps prevent
duplicate practitioner billing. You must also inform the patient of these items and document it in their
medical record:
●
Availability of CCM services
●
Possible cost sharing responsibilities
●
Only 1 practitioner can furnish and bill CCM services during a calendar month
●
Patient’s right to stop CCM services at any time (eective the end of calendar month)
Patients need to provide informed consent only once unless they switch to a dierent CCM practitioner.
MLN BookletChronic Care Management Services
MLN909188 September 2022Page 8 of 15
Recording Patient Health Information
Record the patient’s demographics, problems, medications, and medication allergies using certied
Electronic Health Record (EHR) technology. This means a version of certied EHR that’s acceptable
under the EHR Incentive Programs as of December 31 of the Calendar Year (CY) preceding each
Medicare PFS payment year. Promoting Interoperability has more information.
Comprehensive Care Plan
●
Person-centered, electronic care plan
based on physical, mental, cognitive,
psychosocial, functional, and environmental
(re)assessment, and inventory of resources
and supports
●
Comprehensive care plan for all
health issues with focus on
managing chronic conditions
●
Provide patients and or caregivers
with copy of the care plan
●
Make electronic care plan available
and shared promptly both within and
outside the billing practice with individuals
involved in patient’s care
●
Several organizations make
care planning tools and resources
publicly available
Comprehensive Care Plan
A comprehensive care plan for all health issues
typically includes, but isn’t limited to:
●
Problem list
●
Expected outcome and prognosis
●
Measurable treatment goals
●
Cognitive and functional assessment
●
Symptom management
●
Planned interventions
●
Medication management
●
Environmental evaluation
●
Caregiver assessment
●
Interaction and coordination with outside
resources, practitioners, and providers
●
Requirements for periodic review
●
When applicable, revision of the care plan
Access to Care &
Care Continuity
●
Provide 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualied practitioners
or clinical sta, including providing patients or caregivers with a way to contact health care
practitioners in the practice to discuss urgent needs no matter the time of day or day of week
●
Provide continuity of care with a designated practitioner or member of the care team with whom
the patient can get successive routine appointments
●
Provide patients and caregivers enhanced opportunities to communicate with their practitioners
about their care by phone and through secure messaging, secure web, or other asynchronous
non-face-to-face consultation methods (like email or secure electronic patient portal)
MLN BookletChronic Care Management Services
MLN909188 September 2022Page 9 of 15
Comprehensive Care Management
●
Assess the patient’s medical, functional, and psychosocial needs
●
Make sure the patient receives timely recommended preventive services
●
Review medications and any potential interactions
●
Oversee the patient’s medication self-management
●
Coordinate care with home- and community-based clinical service providers
Manage Care Transitions
●
Manage care transitions between and among health care providers and settings, including referrals
to other clinicians, or follow-up after an emergency department visit or after discharges from
hospitals, skilled nursing facilities, or other health care facilities
●
Create and exchange or share continuity of care document(s) promptly with other practitioners
Concurrent Billing
●
You can’t report complex CCM and non-complex CCM for the same patient in a calendar month
●
Don‘t report 99491 in the same calendar month as 99487, 99489, or 99490
●
You can’t bill CCM during the same service period by the same practitioner as HCPCS codes
G0181 or G0182 (home health care supervision, hospice care supervision) or CPT codes
90951–90970 (certain ESRD services)
●
You can report CCM codes 99487, 99489, 99490 and 99491 by the same practitioner for services
furnished during the 30-day TCM service period (CPT 99495, 99496)
●
You can’t report complex CCM and prolonged Evaluation and Management (E/M) services in the
same calendar month
●
Consult CPT instructions for other codes you can’t bill concurrently with CCM
●
Other practitioner billing restrictions may apply if you’re taking part in a CMS-sponsored model
or demonstration program
●
You can’t count time toward the CCM service code for any other billed code
●
Beginning CY 2022, RHCs and FQHCs can bill CCM and TCM services for the same patient
during the same time period
CPT only copyright 2021 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
Page 10 of 15 MLN909188 September 2022
Principal Care Management
●
Beginning CY 2020, we introduced Principal Care Management (PCM) services to furnish CCM
for patients with a single chronic condition or with multiple chronic conditions but focused on a
single high-risk condition
●
PCM services may be expected to last 6 months–1 year or until patient’s death
●
PCM services require 30 minutes before billing
●
CCM codes require patients have 2 or more chronic conditions expected to last 12 months or until
their death
●
CCM services require 20 minutes before billing
Chronic Care Management & Principal Care Management Codes
In 2021, we added 5 new CPT codes describing PCM services furnished by clinical sta under the
supervision of a NPP.
Table 1. Applicable CPT Codes
CPT Code Descriptor
99424 Principal care management services, for a single high-risk disease, with the following
required elements: one complex chronic condition expected to last at least 3 months,
and that places the patient at signicant risk of hospitalization, acute exacerbation/
decompensation, functional decline, or death, the condition requires development,
monitoring, or revision of disease-specic care plan, the condition requires frequent
adjustments in the medication regimen, and/or the management of the condition is
unusually complex due to comorbidities, ongoing communication and care coordination
between relevant practitioners furnishing care; rst 30 minutes provided personally by
a physician or other qualied health care professional, per calendar month
99425 Principal care management services, for a single high-risk disease, with the following
required elements: one complex chronic condition expected to last at least 3 months,
and that places the patient at signicant risk of hospitalization, acute exacerbation/
decompensation, functional decline, or death, the condition requires development,
monitoring, or revision of disease-specic care plan, the condition requires frequent
adjustments in the medication regimen and/or the management of the condition is
unusually complex due to comorbidities, ongoing communication and care coordination
between relevant practitioners furnishing care; each additional 30 minutes provided
personally by a physician or other qualied health care professional, per calendar
month (List separately in addition to code for primary procedure)
CPT only copyright 2021 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
Page 11 of 15 MLN909188 September 2022
Table 1. Applicable CPT Codes (cont.)
CPT Code Descriptor
99426 Principal care management services, for a single high-risk disease, with the following
required elements: one complex chronic condition expected to last at least 3 months,
and that places the patient at signicant risk of hospitalization, acute exacerbation/
decompensation, functional decline, or death, the condition requires development,
monitoring, or revision of disease-specic care plan, the condition requires frequent
adjustments in the medication regimen and/or the management of the condition is
unusually complex due to comorbidities, ongoing communication and care coordination
between relevant practitioners furnishing care; rst 30 minutes of clinical sta time
directed by physician or other qualied health care professional, per calendar month
99427 Principal care management services, for a single high-risk disease, with the following
required elements: one complex chronic condition expected to last at least 3 months,
and that places the patient at signicant risk of hospitalization, acute exacerbation/
decompensation, functional decline, or death, the condition requires development,
monitoring, or revision of disease-specic care plan, the condition requires frequent
adjustments in the medication regimen and/or the management of the condition is
unusually complex due to comorbidities, ongoing communication and care coordination
between relevant practitioners furnishing care; each additional 30 minutes of clinical
sta time directed by a physician or other qualied health care professional per
calendar month (List separately in addition to code for primary procedure)
99437 Chronic care management services, provided personally by a physician or other qualied
health care professional, 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 signicant risk of death, acute exacerbation/
decompensation, or functional decline, comprehensive care plan established, implemented,
revised or monitored; each additional 30 minutes by a physician or other qualied
health care professional, per calendar month (List separately in addition to code for
primary procedure)
99439* Chronic care management services, each additional 20 minutes of clinical sta time
directed by a physician or other qualied health care professional, per calendar month
*Beginning 2022 we replaced G2058 with 99439.
CPT only copyright 2021 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
Page 12 of 15 MLN909188 September 2022
Table 1. Applicable CPT Codes (cont.)
CPT Code Descriptor
99487 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 signicant risk
of death, acute exacerbation/decompensation, or functional decline, establishment
or substantial revision of comprehensive care plan, moderate or high complexity
medical decision making; rst 60 minutes of clinical sta time directed by a physician
or other qualied health care professional, per calendar month
99489 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 signicant risk
of death, acute exacerbation/decompensation, or functional decline, establishment
or signicant revision of comprehensive care plan, moderate or high complexity
medical decision making; each additional 30 minutes of clinical sta time directed
by a physician or other qualied health care professional, per calendar month (List
separately in addition to code for primary procedure)
99490 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 o
f
the patient, chronic conditions place the patient at signicant risk of death, acute
exacerbation/decompensation, or functional decline, comprehensive care plan
established, implemented, revised, or monitored; rst 20 minutes of clinical sta time
directed by a physician or other qualied health care professional, per calendar month
99491 Chronic care management services, provided personally by a physician or other
qualied healthcare professional, at least 30 minutes of physician or other qualied
healthcare professional time, 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
signicant risk of death, acute exacerbation/decompensation, or functional decline,
comprehensive care plan established, implemented, revised, or monitored
CPT only copyright 2021 American Medical Association. All rights reserved.
Chronic Care Management & Medicare Demonstrations
CCM service codes include care coordination and care management payment for a patient with multiple
chronic conditions within Original Medicare. We won’t duplicate payments for the same or similar
services for patients with chronic conditions already paid under the various demonstration initiatives.
Get more information on potentially duplicated billing by consulting the CMS sta responsible for
demonstration initiatives.
MLN BookletChronic Care Management Services
Page 13 of 15 MLN909188 September 2022
Chronic Care Management Service Summary
Initiating Visit
□
Face-to-face E/M visit, AWV, or IPPE for new patients or patients who the billing
practitioner hasn’t seen within 1 year before CCM services start.
Structured Recording of Patient Health Information
Using Certied EHR Technology
□
Record the patient’s demographics, problems, medications, and medication allergies
using certied EHR technology. A full EHR list of problems, medications, and medication
allergies must inform the care plan, care coordination, and ongoing clinical care.
24/7 Access & Continuity of Care
□
Provide 24/7 access to physicians or other qualied practitioners or clinical
sta, including providing patients or caregivers with a way to contact health care
practitioners in the practice to discuss urgent needs no matter the time of day
or day of week.
□
Provide continuity of care with a designated practitioner or member of the care
team with whom the patient can get successive routine appointments.
Comprehensive Care Management
□
Assess the patient’s medical, functional, and psychosocial needs.
□
Make sure the patient receives timely recommended preventive services.
□
Oversee the patient’s medication self-management.
Comprehensive Care Plan
□ Create, revise, and or monitor (per code descriptors) a person-centered, electronic
care plan based on physical, mental, cognitive, psychosocial, functional,
environmental (re)assessment, and inventory of resources and supports.
□ Comprehensive care plan for all health issues with focus on managing chronic
conditions.
□ Provide patients and or caregivers with copy of the care plan.
□ Electronically capture care plan information and make it available promptly both
within and outside billing practice with individuals involved in the patient’s care, as
appropriate.
MLN BookletChronic Care Management Services
Page 14 of 15 MLN909188 September 2022
Manage Care Transitions
□
Manage care transitions between and among health care providers and settings,
including referrals to other clinicians, or follow-up after an emergency department visit
or after discharges from hospitals, skilled nursing facilities, or other health
care facilities.
□
Create and exchange or share continuity of care document(s) promptly with
other practitioners.
Home- and Community-Based Care Coordination
□
Coordinate care with home- and community-based clinical service practitioners.
□
Communicate with home- and community-based practitioners about the patient’s
psychosocial needs and functional decline and document it in the patient’s
medical record.
Enhanced Communication Opportunities
□
Provide patients and caregivers enhanced opportunities to communicate with their
practitioners about their care by phone and through secure messaging, secure web,
or other asynchronous non-face-to-face consultation methods (like email or secure
electronic patient portal).
Patient Consent
□
Inform patient that:
□
CCM services are available
□
They may have cost sharing responsibilities
□
Only 1 practitioner can furnish and bill CCM services during a calendar month
□
They can stop the CCM services at any time (eective the end of calendar month)
□
Document in patient’s medical record that you explained the required information
and whether they accepted or declined services.
Medical Decision-Making
□
Complex CCM services require and include moderate to high complexity medical
decision-making (by the physician or other billing provider).
MLN BookletChronic Care Management Services
Page 15 of 15 MLN909188 September 2022
Resources
●
CCM Materials for FQHCs
●
CCM Materials for RHCs
●
CCM Materials for Hospital Outpatient Departments
●
CCM Materials for Physicians
●
Chronic Conditions Data Warehouse
●
Connected Care: CCM
●
Find Your Medicare Administrative Contractor (MAC’s) Website
●
Health Disparities & CCM
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The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department
of Health & Human Services (HHS).
