Chronic Care Management

Effective Date: November 15, 2020

Purpose:
This policy provides guidelines for reimbursement of Chronic Care Management services for both participating and non-participating providers.

Scope:
Products included:

  • NJ FamilyCare/Medicaid Plan
  • Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

  • CPT Code 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
  • CPT Code 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 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; 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)
  • CPT Code 99490: 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 significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.
  • CPT Code 99491: Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, 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 significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored

Policy:
Chronic Care Management (CCM) reimburses providers of members with chronic conditions for non-face-to-face care coordination services, including communication with other treating health professionals, medication management and plan of care maintenance. CCM improves a member’s access to primary care with certified electronic health/medical records technology and other coordination of care. These services include clinical staff, under the direction of a physician or other qualified health care professional to a patient residing at home or in a domiciliary, rest home, or assisted living facility.

Care Management includes but is not limited to:

  • Communication with the member, family members and/or other professionals regarding the member’s care
  • Education to the member, family members and/or caretaker
  • Maintaining a comprehensive electronic care plan
  • Structured recording of the member’s health information
  • Managing transitions of care and other care management services

In order to be reimbursed for Chronic Care Management, the member must have two (2) or more chronic conditions (expected to last at least 12 months) with significant risk of death, functional decline, exacerbation or decompensation - E.g., cancer, hypertension, heart disease, diabetes, atrial fibrillation, stroke, HIV/AIDS etc.

Documentation must include:

  • Narrative with the need for CCM
  • A comprehensive care plan (with measurable goals) established, implemented, revised or significantly monitored
  • Support services rendered
  • Time spent on CCM services

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon NJ Health shall allow Chronic Care Management services (CPT codes 99487, 99489, 99490 and 99491) when the member meets the eligibility requirements of two (2) or more chronic conditions. Only one (1) type of CCM code shall be reimbursed per month by a primary care physician and non-practitioner physicians.

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.

Do not bill these codes in the same month as Transitional Care Management codes (99495–99496), End Stage Renal Disease codes (90951–90970) or Home Health/Hospice Care codes (G0181–G0182).

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Benefit Limitations
  • The terms of any applicable provider participation agreement;
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
  • Medical necessity; and
  • Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:
CMS MLN #909188, Chronic Care Management Services, July 2019

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

CMS Frequently Asked Questions about Physician Billing for Chronic Care Management Services, January 2019

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf

CMS Chronic Conditions Overview

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services