As a medical care provider, understanding billing codes can help your practice project revenues and optimize your staff’s capacity.
Utilizing the CPT codes for Medicare’s wellness program, Chronic Care Management (CCM), can provide an optimal vantage point of both patient and Medicare expectations. Additionally, CPT codes provide an understanding of CCM billing expectations and standards.
A review of 2023 CCM requirements and CPT codes fosters a more comprehensive awareness of CCM billing opportunities, criteria, timeframes, and standards. You will also see how care coordination software can simplify the program for your practice.
At ThoroughCare, we’ve worked with clinics and physician practices nationwide to help them streamline and capture Medicare reimbursements. Our software solution assists with CCM rules and regulations while also tracking all activities related to providing the program and easing the difficulties of billing.
Medicare designed CCM so doctors and healthcare groups can provide ongoing treatment to patients between regular appointments delivered through remote interactions. Determined as a monthly program, at least 20 minutes of patient service must be provided each month for Medicare to offer CCM reimbursement.
A patient’s CCM eligibility necessitates having two or more chronic conditions expected to last a minimum of 12 months. Additionally, the patient’s doctor must note any chronic issues 12 months prior to CCM enrollment. These chronic conditions must pose a significant risk of death, acute decompensation, or functional decline.
CCM services can include:
Individual care plans are created for and in collaboration with the patient upon CCM enrollment and determine services rendered. These care plans act as a comprehensive guide to the patient’s goals, health history, and behavior.
Medicare Part B covers 80% of this benefit for patients.
On average, providers receive $62.69 for 20 minutes of service per month. Additional opportunities to meet higher billing thresholds are also available, as detailed below.
Five items are required to submit a claim through the Centers for Medicare & Medicaid Services (CMS):
Although not a requirement, it is helpful to know the care manager assigned to the case in the event of an audit.
To bill, calculate the time spent with each patient per month.
Four steps to bill for services:
See 2025 reimbursement rates here.
Chronic care CPT codes will vary based on the type of service provider and complexity of care. Each code reflects a different value and the amount of time dedicated to care management.
The following rates are based on national averages for the reimbursement of non-complex chronic care by clinical staff and may vary based on locality as determined by the CMS Physician Fee Schedule.
Rural health clinics (RHCs) and federally qualified health clinics (FQHCs) utilize the following CPT code for "general care management” to bill for CCM.
Two ICD-10s must be presented when billing for chronic care services as the requirement for CCM includes two or more present conditions.
The following codes are designed for non-complex chronic care in which the provider or non-physician practitioner (NPP) is heavily involved. They cannot be billed concurrently with standard CCM CPT codes.
The value of physicians’ time is reflected in these non-complex, physician-driven codes as CCM services are not reliant on clinical staff:
The following billing codes apply for complex care:
It is important to note the distinction here between CPT code 99487, which accounts for 60 minutes of complex chronic care, versus the two CPT codes (99491 and 99437) that account for 60 minutes of physician-driven, non-complex chronic care.
In the case of a Medicare audit, you will want to show the correct code was applied based on the compatible situation.
CCM is distinctly valuable as it can generate revenue, recover costs, and broaden care access for your patients.
The final figure in the graphic does not account for complex or physician-driven CCM services, nor does it include additional billable time beyond the 20-minute minimum. Both could produce a higher figure.
To deliver and accurately document CCM services, you will want a system in place to best manage your program.
A practical resource, such as care coordination software, secures key details from being lost or overlooked. This promotes efficiency for you and your staff, which subsequently helps patients succeed.
Care coordination software can streamline the creation of patient care plans, support staff workflows, and simplify billing. ThoroughCare’s software solution offers these exact features.
With a clinician’s eye, we have designed an intuitive platform that untangles the entire CCM process, so you and your patients can capitalize on it. Our care coordination software solution enables you to offer an entire suite of wellness services that pair well with CCM, such as Behavioral Health Integration (BHI) or Remote Patient Monitoring (RPM).
Reimbursement rates are based on a national average and may vary depending on your location. Check the Physician Fee Schedule for the latest information.