Coding and Billing for Care Coordination

How can a medical home afford a care coordinator?

Approaches to funding a care coordinator may include:

Chronic Care Management Services

In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for Chronic Care Management services furnished to Medicare patients with multiple chronic conditions. Then, recognizing that suboptimal management of chronic conditions can lead to declines in health, significant morbidity, or potential mortality, some of the language and regulations regarding CCM codes were relaxed in 2016 to increase the amount of CCM Services being performed.
Below is a list of the 3 CPT codes related to CCM, along with some brief general guidelines for billing these services.
Chronic Care Management - CPT 99490 - for at least 20 minutes
“Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, 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 a significant risk of death, acute exacerbation/decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored”
Example: During the month, a care coordinator spends time in care plan monitoring for a patient with Asthma and ADHD that has already consented to CCM. The care coordinator spends a total of 20 minutes of non-face-to-face care management services following-up with family regarding effectiveness of patients’ asthma controller medication after an exacerbation and ER visit the previous month.
Coding: CPT 99490 (Chronic care management service, 20 minutes)
Complex Chronic Care Management (CPT codes 99487 and 99489)
CPT 99487 - for first 60 minutes
“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”
Example: “Office visit with an established 20-year-old female patient with spastic quadriplegia due to cerebral palsy.” During this regular chronic care visit the physician talks with the young adult and parent about transition of care to adult provider. After the visit, “the pediatrician and clinical staff devote an additional 60 minutes to non-face-to-face care management services to prepare the transfer letter, contact the young adult’s other specialists to coordinate the transfer information, consult with the new adult doctor, and call the young adult to review final plans for transfer, with the date for the initial adult appointment.”
Coding after the visit: CPT 99487 (Complex, chronic care management service, 60 minutes)
CPT 99489 – for additional time beyond 60 minutes
“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)"
Example: "A week after a visit with an established 20-year-old female patient with spastic quadriplegia due to cerebral palsy, but within the same calendar month. The clinical staff devote an additional 30 minutes to non-face-to-face care management services to prepare the transfer letter, contact the young adult’s other specialists to coordinate the transfer information, consult with the new adult doctor, and call the young adult to review final plans for transfer, with the date for the initial adult appointment.”
Coding: CPT 99489 (Complex, chronic care management service, additional 30 minutes)
General Guidelines
Patient Eligibility: The billing practitioner can bill either complex or regular CCM in a calendar month, but not both.
Initiating Visit: If a patient hasn’t been seen in the prior 12 months, an initiating visit is required, and either verbal or written consent needs to be obtained and listed in the EMR. If the patient has been seen in the prior 12 months, an initiating visit isn’t required, but documented consent still must be obtained.
Patient Consent: Advanced consent is required and must include the following:
  • “The availability of CCM services and applicable cost-sharing
  • That only one practitioner can furnish and be paid for CCM services during a calendar month
  • The right to stop CCM services at any time.

Resources

Information & Support

For Professionals

Chronic Care Management Services - Fact Sheet (PDF Document 554 KB)
DHHS/Centers for Medicare & Medicaid Services put together this extensive fact sheet on Chronic Care Management (CCM). It provides background on payable CCM service codes, identifies eligible practitioners and patients, and details the Medicare PFS billing requirements.

CMS Chronic Care Management Services Changes for 2017 (PDF Document 521 KB)
Chronic Care Management (CCM) services by a physician or non-physician practitioner and their clinical staff, per calendar month, for patients with two or more chronic conditions expected to last at least 12 months.

Coding and Reimbursement Health Care Transition Tipsheet 2017 (PDF Document 925 KB)
A 2017 Coding and Reimbursement health care transition (from pediatric to adult health care) tip sheet put together by Got Transition and the AAP with 2 new components.

Authors & Reviewers

Last update/revision: November 2018
Current Authors and Reviewers:
Authors: Jennifer Goldman-Luthy, MD, MRP, FAAP
Gina Pola-Money
Kathy Heffron, RN
Contributing Author: Mindy Tueller, MS
Reviewers: Alfred N. Romeo, RN, PhD
Barbara Ward, RN BS