Chronic Care Management (CCM) services are essential in the ongoing care of patients with multiple chronic conditions, offering continuous support and coordination of care to improve health outcomes and reduce healthcare costs. The Centers for Medicare & Medicaid Services (CMS) recognizes CCM as a critical service and provides reimbursement for these non-face-to-face services under the Medicare Physician Fee Schedule (PFS).

What Are Chronic Care Management Services?

CCM services focus on the comprehensive management of patients with two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. These conditions place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline. Examples of chronic conditions include diabetes, hypertension, heart failure, asthma, and chronic kidney disease.

CCM services typically include:

• Structured Recording of Patient Health Information: Maintaining accurate and up-to-date patient health records is vital for ongoing care.
• Comprehensive Care Plan: Developing, implementing, and updating a patient-centered care plan that addresses all health issues, with a focus on managing chronic conditions.
• Care Coordination: Ensuring that all healthcare providers involved in a patient’s care are informed and coordinated, including referrals, transitions between healthcare settings, and communication with community-based services.
• Access to Care: Providing patients with 24/7 access to care and health information, ensuring continuity of care and addressing urgent needs promptly.

Who Can Provide CCM Services?

CCM services can be provided by a variety of healthcare practitioners, including:

• Physicians
• Nurse Practitioners (NPs)
• Physician Assistants (PAs)
• Clinical Nurse Specialists (CNSs)
• Certified Nurse Midwives (CNMs)

These services are often provided by clinical staff under the general supervision of a billing practitioner, meaning the practitioner oversees the services but does not need to be physically present when they are delivered.

Billing and Coding for CCM Services

CCM services are billed using specific Current Procedural Terminology (CPT) codes that correspond to the complexity and duration of the services provided. Some of the relevant CPT codes include:

• 99490: Non-complex CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99487: Complex CCM services, first 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
• 99491: CCM services provided personally by a physician or other qualified healthcare professional, first 30 minutes, per calendar month.

Healthcare providers must ensure accurate and compliant billing practices, as improper billing can lead to denied claims or audits.

Patient Eligibility and Consent

Before initiating CCM services, healthcare providers must confirm that patients meet the eligibility criteria—having two or more chronic conditions—and obtain the patient’s consent. This consent must inform the patient of the nature of CCM services, their cost-sharing responsibilities, and their right to stop services at any time.

The Role of CCM in Reducing Healthcare Disparities

CCM services are particularly important in addressing healthcare disparities, especially for patients in rural or underserved areas. By providing continuous care and support, CCM can help manage chronic conditions more effectively, reducing the need for more costly interventions such as emergency room visits or hospital admissions.

For more detailed information on billing and guidelines, healthcare providers can refer to the CMS Chronic Care Management Services Guide.