Page 1 of 12
Chronic Care Management Services
MLN909188 May 2024
CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable
FARS/HHSARS apply. 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.
What’s Changed?
●
Added new codes describing chronic pain management and treatment (page 10)
●
Added information about other care management services (page 11)
Substantive content changes are in dark red.
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 2 of 12
Table of Contents
What’s Changed? ................................................................................................................................ 1
Chronic Care Management Service Elements: Highlights .............................................................. 3
Chronic Care Management Service Practitioners ............................................................................ 4
Supervision .......................................................................................................................................... 4
Patient Eligibility
.................................................................................................................................. 4
Initiating V
isit ....................................................................................................................................... 5
Patient Consent ................................................................................................................................... 6
Electronic Recording of Patient Health Information ........................................................................ 6
Comprehensive Care Plan .................................................................................................................. 6
Medical Decision-Making .................................................................................................................... 7
Access to Care & Care Continuity ..................................................................................................... 7
Comprehensive Care Management.................................................................................................... 7
Manage Care Transitions
.................................................................................................................... 8
Concurrent Billing ............................................................................................................................... 8
Chronic Care Management Codes ..................................................................................................... 9
Other Care Management Services ....................................................................................................11
Resources .......................................................................................................................................... 12
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 3 of 12
CMS recognizes chronic care management (CCM) as
a critical primary care service that contributes to better
Medicare patient health and care.
We pay for CCM services provided to patients with multiple
chronic conditions under the Medicare Physician Fee
Schedule (PFS).
As the billing practitioner, you don’t 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.
NOTE: Information in this
publication applies only to the
Medicare Fee-for-Service Program
(also known as Original Medicare).
NOTE: In this booklet, you refers
to practitioners. We refers to CMS.
Chronic Care Management Service Elements: Highlights
CCM services are extensive, including:
●
Structured recording of patient health information
●
Maintaining 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.
You’ll typically provide CCM services outside of face-to-face patient visits and focus on advanced
primary care characteristics like:
●
Continuous patient relationship with a chosen care team member
●
Supporting the patient with a chronic disease in achieving health goals
●
24/7 patient access to care and health information
●
Patient getting preventive care
●
Patient and caregiver engagement
●
Prompt sharing and using patient health information
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 4 of 12
Chronic Care Management Service Practitioners
These physicians and non-physician practitioners 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
also provide and bill them. 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.
For CCM services the billing practitioner doesn’t personally provide, the clinical sta can provide
them under direction of the billing practitioner on an “incident to” basis (as an integral part of services
provided by the billing practitioner), subject to applicable state law, licensure, and scope of practice.
Clinical sta are employees or people working under contract with the billing practitioner, and we
directly pay those practitioners for CCM services.
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 provide the service, it’s done under their overall direction and control. We don’t require the
physician to be physically present while the service is provided.
Patient Eligibility
Eligible CCM patients will have multiple (2 or more) chronic conditions that are expected to last
at least 12 months or until the patient’s death or that place them at signicant risk of death, acute
exacerbation or decompensation, or functional decline. These services aren’t typically face-to-face
and allow eligible practitioners to bill at least 20 minutes or more of care coordination services per
month. Check Medicare eligibility.
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 (ED) visits) or the typical patient prole in the CPT prefatory language.
CPT only copyright 2023 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 5 of 12
CCM services can also help reduce geographic and racial or ethnic health care disparities.
Examples of chronic conditions include, but aren’t limited to:
●
Alcohol abuse
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Alzheimer’s disease and related dementia
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Arthritis (osteoarthritis and rheumatoid)
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Asthma
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Atrial brillation
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Autism spectrum disorders
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Cancer (breast, colorectal, lung, and prostate)
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Cardiovascular disease
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Chronic kidney disease
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Chronic obstructive pulmonary disease (COPD)
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Depression
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Diabetes
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Heart failure
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Hepatitis (chronic viral B & C)
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HIV and AIDS
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Hyperlipidemia (high cholesterol)
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Hypertension (high blood pressure)
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Ischemic heart disease
●
Osteoporosis
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Schizophrenia and other
psychotic disorders
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Stroke
●
Substance use disorders
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 a patient’s health, rather than only
treating severe or acute disease and illness.
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 the previous 1 year. The initiating visit can happen during a
comprehensive face-to-face evaluation and management (E/M) visit, annual wellness visit (AWV), or
initial preventive physical exam (IPPE).
If the practitioner doesn’t discuss CCM during an E/M visit, AWV, or IPPE, it can’t count as the
initiating visit. A face-to-face initiating visit isn’t part of CCM and can be separately billed.
Practitioners who personally provide extensive assessment and care planning outside the usual eort
described by the initiating visit and CCM codes may also bill HCPCS code G0506 once, as part of an
initiating visit.
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 6 of 12
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 and also helps prevent duplicate practitioner
billing. You must also inform the patient of these items and document them in their medical record:
●
The availability of CCM services
●
Their possible cost sharing responsibilities
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That only 1 practitioner can provide and bill CCM services during a calendar month
●
The patient’s right to stop CCM services at any time (eective at the end of the calendar month)
●
That the practitioner explained the required information and whether the patient accepted or
declined services
Patients need to provide informed consent only once unless they switch to a dierent CCM practitioner.
Electronic Recording of Patient Health Information
Record the patient’s demographics, problems, medications, and medication allergies using a version
of certied electronic health record (EHR) that’s acceptable under the EHR Incentive Programs as of
December 31 of the CY before each Medicare PFS payment year. Promoting Interoperability Programs
has more information about EHR technology.
Comprehensive Care Plan
The comprehensive care plan for all health issues with a focus on managing chronic conditions should:
●
Create, revise, and monitor (per code descriptors) a person-centered, electronic care plan based
on physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an
inventory of resources and supports
●
Provide patients and caregivers with a copy of the care plan
●
Electronically capture the care plan information, and make it available promptly both within and
outside the billing practice with people involved in the patient’s care, as appropriate
We have several care planning tools and resources.
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 7 of 12
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
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Planned interventions
●
Medication management
●
Environmental evaluation
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Caregiver assessment
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Interaction and coordination with outside
resources, practitioners, and providers
●
Requirements for periodic review
●
When applicable, revision of the care plan
Medical Decision-Making
Complex CCM services require and include moderate to high complexity medical decision-making by
the physician or other billing practitioner.
Access to Care & Care Continuity
Access to care and care continuity should include:
●
Providing 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 their health care
practitioners to discuss urgent needs no matter the day or time
●
Providing continuity of care with a designated care team member with whom the patient can schedule routine
appointments and who’s regularly in touch with the patient to help them manage their chronic conditions
●
Providing patients and caregivers a way 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 a secure electronic patient portal)
Comprehensive Care Management
Comprehensive care management should:
●
Assess the patient’s medical, functional, and psychosocial needs
●
Make sure the patient gets timely recommended preventive services
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Review medications and any potential interactions
●
Oversee the patient’s medication self-management
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Coordinate care with home- and community-based clinical service providers
●
Communicate with home- and community-based providers about the patient’s psychosocial needs
and functional decline, and document it in the patient’s medical record
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 8 of 12
Manage Care Transitions
You can manage care transitions between and among health care providers and settings by:
●
Including referrals to other clinicians, or following up after an ED visit or after discharges from
hospitals, skilled nursing facilities, or other health care facilities
●
Creating and exchanging or sharing continuity of care documents promptly with other practitioners
Concurrent Billing
Consider these guidelines when billing for concurrent services:
●
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
provided during the 30-day transitional care management (TCM) service period (CPT codes
99495, 99496)
●
You can’t report complex CCM and prolonged E/M services in the same calendar month
●
You can’t count time toward the CCM service code for any other billed code
●
RHCs and FQHCs can bill CCM and TCM services for the same patient during the same period
●
Remote physiologic monitoring (RPM) and remote therapy monitoring (RTM) can be billed
concurrently with CCM and TCM
●
Practitioners may bill either RPM and RTM, but not both, concurrently with any CCM or TCM service
●
Consult CPT instructions for other codes you can’t bill concurrently with CCM
●
Other provider billing restrictions may apply if you’re taking part in a CMS-sponsored model or
demonstration program
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.
CPT only copyright 2023 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
Page 9 of 12
Chronic Care Management Codes
MLN909188 May 2024
Applicable CCM Codes
Code Descriptor
99437
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 that 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 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 that place the patient at signicant risk of death,
acute exacerbation/decompensation, or functional decline, comprehensive care
plan established, implemented, revised, or monitored; each additional 20 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)
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 that place the patient at signicant risk of
death, acute exacerbation/decompensation, or functional decline, comprehensive
care plan established, implemented, revised, or monitored, 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 that place the patient at signicant risk of
death, acute exacerbation/decompensation, or functional decline, comprehensive
care plan established, implemented, revised, or monitored, 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)
*CPT codes 99487, 99489, and 99490 include time spent directly by the billing practitioners or clinical sta. Time spent by
the billing practitioner may also count toward the time threshold if not used to report 99491.
CPT only copyright 2023 American Medical Association. All rights reserved.
Applicable CCM Codes (cont.)
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 10 of 12
Code Descriptor
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
of the patient, chronic conditions that 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 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 that place the patient at signicant risk of death,
acute exacerbation/decompensation, or functional decline, comprehensive care plan
established, implemented, revised, or monitored; rst 30 minutes provided personally
by a physician or other qualied health care professional, per calendar month
G3002
Chronic pain management and treatment, monthly bundle including, diagnosis;
assessment and monitoring; administration of a validated pain rating scale or tool;
the development, implementation, revision, and/or maintenance of a
person-centered care plan that includes strengths, goals, clinical needs, and
desired outcomes; overall treatment management; facilitation and coordination of
any necessary behavioral health treatment; medication management; pain and
health literacy counseling; any necessary chronic pain related crisis care; and
ongoing communication and care coordination between relevant practitioners
furnishing care, e.g. physical therapy and occupational therapy, complementary
and integrative approaches, and community-based care, as appropriate. required
initial face-to-face visit at least 30 minutes provided by a physician or other
qualied health professional; rst 30 minutes personally provided by physician or
other qualied health care professional, per calendar month. (when using g3002,
30 minutes must be met or exceeded.)
G3003
Each additional 15 minutes of chronic pain management and treatment by a physician
or other qualied health care professional, per calendar month. (list separately in
addition to code for g3002. when using g3003, 15 minutes must be met or exceeded.)
*CPT codes 99487, 99489, and 99490 include time spent directly by the billing practitioners or clinical sta. Time spent by
the billing practitioner may also count toward the time threshold if not used to report 99491.
**CPT code 99491 includes only time that’s spent personally by the billing practitioner. Clinical sta time doesn’t count
toward the required reporting time threshold code.
CPT only copyright 2023 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 11 of 12
Other Care Management Services
Principal Care Management
Principal care management (PCM) provides 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 to 1 year or until the patient’s death and require
30 minutes of service before billing.
PCM Codes: 99424, 99425, 99426, and 99427
Principal Illness Navigation & Community Health Integration
Principal illness navigation (PIN) services can be provided following an initiating E/M visit that
addresses a serious high-risk condition, illness, or disease, with these characteristics:
● One serious, high-risk condition expected to last at least 3 months and that places the
patient at signicant risk of hospitalization, nursing home placement, acute exacerbation or
decompensation, functional decline, or death
● The
condition requires developing, monitoring, or revising a disease-specic care plan and may require
frequently adjusting the medication or treatment regimen or substantial assistance from a caregiver
PIN Codes: G0023, G0024, G0140, and G0146
Community health integration (CHI) services help patients who have unmet social needs that aect
the diagnosis and treatment of their medical problems identify and connect with appropriate clinical
and social support resources.
Practitioners may provide CHI services monthly, as medically necessary, following an initiating E/M visit
(CHI initiating visit) where the practitioner identies the presence of social determinants of health needs
that signicantly limit their ability to diagnose or treat the patient problems addressed in the visit.
Community health workers, care navigators, peer support specialists, and other auxiliary personnel
may be employed by community-based organizations if the billing practitioner provides the required
supervision for these services, like other care management services.
CHI Codes: G0019 and G0022
CPT only copyright 2023 American Medical Association. All rights reserved.
MLN BookletChronic Care Management Services
MLN909188 May 2024Page 12 of 12
Resources
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CCM Materials for FQHCs
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CCM Materials for RHCs
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CCM Materials for Hospital Outpatient Departments
●
CCM Materials for Physicians
●
FAQs for CCM Billing
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of Health & Human Services (HHS).
