2021 CMS Code Updates: Chronic Care Management (CCM)

Medicare covers chronic care management services if a patient has two or more serious conditions that are expected to last at least a year.

•  Health systems, centers, FQHCs, ACOs, and more often question the correct way to implement CCM for Medicare utilizing CPT^® 99490, 99491, 99487, 99489 and 99439.

•  CPT^® added a new CCM code in 2021, +99439. It may be used with code 99490 to report each additional 20 minutes of clinical staff time doing CCM. The definition of code 99490 was amended from “20 minutes” to “first 20 minutes.”

Chronic care management services are service provided to patients who have medical and/or psychosocial needs requiring establishing, implanting and monitoring a care plan. By definition, they are for patients who have two or more chronic illness expected to last for at least 12 months, or until the death of the patient, that place them at significant risk of death, acute exacerbation/decompensation or functional decline.

Some of the codes describe care provided by a physician or non-physician practitioner (NPP), and some describe services performed by clinical staff under the supervision and direction of a physician or NPP. If the service is provided by the physician/NPP, do not double count time spent in any other, billable activity.  All are for time during a calendar month.

They are divided into chronic care management and complex chronic care management. CPT® defines chronic care management for adults as those who are typically treated with three or more prescriptions and may be receiving other therapeutic interventions, such as PT or OT. For pediatric patients, there are three or more typical interventions, such as medications, nutritional support, or respiratory therapy. Typical patients have complex diseases and morbidities, and demonstrate the need for:

• need for the coordination of a number of specialties and services;
• inability to perform activities of daily living and/or cognitive impairment resulting in poor adherence to the treatment plan without substantial assistance from a caregiver;
• psychiatric and other medical comorbidities (eg, dementia and chronic obstructive pulmonary disease or substance abuse and diabetes) that complicate their care; and/or
• social support requirements or difficulty with access to care. ^[1]

Complex chronic care management has longer threshold times to bill, as well.

Additional requirements:

• Verbal consent from the patient
• Development of a comprehensive care plan
• The patient must have a designated physician/NPP as their clinician, and have 24/7 access to address urgent needs
• The practice must use a certified electronic health record, although faxing is allowed to share the care plan
•  Use a standardized method to identify patients who are eligible for the service
• Manage care transitions
• Give a copy of the plan to the patient

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 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.

+ 99489 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)

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 place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
• Comprehensive care plan established, implemented, revised, or monitored;

First 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.