FAQs
Additional Information
Frequently Asked Questions about Physician Billing for Chronic Care Management Services
This document answers frequently asked questions about billing chronic care management (CCM) services to the Physician Fee Schedule (PFS) under CPT codes 99487, 99489, 99490 and 99491.
1. Can all of these CPT codes be billed together for a given patient in a given month by a given practitioner?
No, only one type of CCM is furnished per service period. CPT reporting rules apply, where CPT code 99491 cannot be reported for the same calendar month as CPT codes 99487, 99489 or 99490. Complex CCM (CPT codes 99487, 99489) cannot be reported for the same calendar month as any other CCM service code. CPT codes 99487 and 99489 may be reported for the same calendar month as each other if the time requirement for reporting both codes (the base and the add-on code) is met.
2. For the CCM codes describing time spent per calendar month by “clinical staff,” who qualifies as “clinical staff”? If the billing physician (or other billing practitioner) furnishes services directly, can their time count towards the clinical staff time required to bill ?
Practitioners should consult the CPT definition of the term “clinical staff.” In addition, time spent by clinical staff may only be counted if Medicare’s applicable “incident to” rules are met such as supervision, applicable State law, licensure and scope of practice. Of course, other staff may help facilitate CCM services, but only time spent by clinical staff can be counted. If the billing practitioner performs CCM services themselves, the time of the billing practitioner may be counted as clinical staff time or, alternatively, applied towards reporting professional CCM (CPT code 99491).
3. For the CCM codes describing time spent per calendar month by “clinical staff,” do the times listed for the work of the billing practitioner mean that the billing practitioner must spend that amount of time each month, in addition to the clinical staff time in the code descriptors, in order to bill CCM?
No, for these codes, these times should be considered like the typical times for evaluation and management (E/M) office visits. They are assumed times, established through physician survey by the American Medical Association when the codes were created and valued, for how much time the billing practitioner spends himself or herself each month, but are not exact times. The billing practitioner’s time could be spent in activities such as directing clinical staff; personally performing clinical staff activities; or in the case of complex CCM, performing moderate to high complexity medical decision making.
4. Can CCM services be subcontracted out to a case management company? What if the clinical staff employed by the case management company are located outside of the United States?
Complex CCM (CPT codes 99487 and 99489) includes moderate to high complexity medical decision making by the billing practitioner during the service period, an activity that cannot be delegated or subcontracted to any other individual. Similarly, professional CCM (CPT code 99491) describes work that is personally performed by the billing practitioner, so it cannot be delegated to any other individual. Regular (“non-complex”) CCM (CPT code 99490) assumes 15 minutes of work by the billing practitioner and this part of the service cannot be delegated. All CCM service codes are valued to include ongoing oversight, management, collaboration and reassessment by the billing practitioner consistent with the included service elements. This work cannot be delegated or subcontracted to any other individual.
A billing practitioner may arrange for clinical staff activities to be provided by an individual(s) external to the practice (for example, in a case management company) if all of the applicable “incident to” and other rules for the PFS are met and there is clinical integration among the care team members. If there is little oversight by the billing practitioner or a lack of clinical integration between a third party providing CCM and the billing practitioner, we do not believe CCM could actually be furnished and therefore the practitioner should not bill for CCM. Because there is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9), CCM services cannot be billed if they are provided to patients or by individuals located outside of the United States.
5. Does the billing practice have to furnish every scope of service element in a given service period, even those that may not apply to an individual patient?
It is our expectation that all of the scope of service elements will be routinely provided in a given service period, unless a particular service is not medically indicated or necessary (for example, the beneficiary has no hospital admissions that month, so there is no management of a transition after hospital discharge). All the parts of the CPT code descriptor(s) must be furnished in order to bill.
6.When should the CCM claim be submitted?
The CCM service period is one calendar month. Practitioners may report CCM at the conclusion of the service period, or after completion of the minimum required service time.
7. What place of service (POS) should be reported on the physician claim?
CCM is priced under the PFS in both the facility and non-facility settings. The billing practitioner should report the POS for the location where he or she would ordinarily provide face-to-face care to the beneficiary. Our goal is to pay under the PFS for CCM furnished to beneficiaries in any care setting, but to also pay an accurate rate that reflects the resource costs of the practitioner him or herself. We welcome information from stakeholders regarding how often they furnish CCM to beneficiaries who reside or remain in facility settings during part or all of the service period, what kind of facilities, and how often the resources and staff of the billing practitioner are used rather than facility resources and staff in the provision of CCM. We recognize that there could be many different arrangements based on the location(s) of the beneficiary during the month and individual practice patterns.
8. Can I bill for CCM services furnished to beneficiaries in skilled nursing facilities, nursing facilities, assisted living or other facility settings?
Yes. CCM is priced under the PFS in both the facility and non-facility settings. The POS on the claim should be the location where the billing practitioner would ordinarily provide face-to-face care to the beneficiary, see above.
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9. Is a new patient consent required each calendar month or annually?
No, as provided in the calendar year (CY) 2014 PFS final rule with comment period (78 FR 74424), a new consent is only required if the patient changes billing practitioners, in which case a new consent must be obtained and documented by the new billing practitioner prior to furnishing the service.
10. If a practitioner arranges to furnish CCM services to his/her patients “incident to” using a case management entity outside the billing practice, does the billing practitioner need to ever see the patient face-to-face?
Yes, for new patients or patients not seen within a year prior to the commencement of CCM services, CCM must be initiated by the billing practitioner during a “comprehensive” E/M visit, annual wellness visit (AWV) or initial preventive physical exam (IPPE). This face-to-face visit is not part of the CCM service and can be separately billed to the PFS, but is required for the specified patients before CCM services can be provided directly or under other arrangements. The billing practitioner must discuss CCM with the patient at this visit. While informed patient consent does not have to be obtained during this visit, it is an opportunity to obtain the required consent. The face-to- face visit included in transitional care management (TCM) services (CPT 99495 and 99496) qualifies as a “comprehensive” visit for CCM initiation. Levels 2 through 5 E/M visits (CPT 99212 through 99215) also qualify; CMS is not requiring the practice to initiate CCM during a level 4 or 5 E/M visit. However CPT codes that do not involve a face-to-face visit by the billing practitioner or are not separately payable by Medicare (such as CPT 99211, anticoagulant management, online services, telephone and other E/M services) do not meet the requirement for the visit that must occur before CCM services are furnished. If the practitioner furnishes a “comprehensive” E/M, AWV, or IPPE and does not discuss CCM with the patient at that visit, that visit cannot count as the initiating visit for CCM.
11. Do face-to-face activities count as billable time?
CCM includes, in large part, activities that are not typically or ordinarily furnished face-to-face with the beneficiary and others, such as telephone communication, review of medical records and test results, and coordination and exchange of health information with other practitioners and providers.
Prior to separate payment for CCM, these activities were primarily included in the payment for face-to-face visits (though they usually occurred before or after), and we tend to refer to them as “non-face-to-face” activities because generally, they are such. If these activities are occasionally provided face-to-face for convenience or other reasons, the time may be counted towards a CCM service code(s). CCM also includes activities such as patient education or motivational counseling
that are frequently provided to patients either in person or non-face-to-face (such as by phone). If the practitioner believes a given beneficiary would benefit or engage more in person, or for similar reasons recommends a given beneficiary receive certain CCM services in person, they may still count the activity as billable time. In all cases, the time and effort cannot count towards any other code if it is counted towards CCM.
12. Medicare and CPT allow billing of E/M visits during the same service period as CCM. If an E/M visit or other E/M service is furnished the same day as CCM services, how do I allocate the total time between CCM and the other E/M code(s)?
CCM services are E/M services. Time or effort that is spent providing services within the scope of the CCM service, on the same day as an E/M visit or other E/M service that Medicare and CPT allow to be reported during the CCM service period, can be counted towards CCM codes, as long as it is not counted towards other reported E/M code(s). We note that time and effort cannot be counted twice, whether face-to-face or non-face-to-face, and Medicare and CPT provisions specify certain codes that can never be billed during the CCM service period (see below).