This document provides coding and billing guidelines for Care Management Services. Providers may obtain additional information in the Current Procedural Terminology (CPT) manual for the guidelines and CPT documentation requirements.
Coding & Billing Guidelines
Chronic Care Management (CCM) & Complex Chronic Care Management (CCCM)
Care management for chronic conditions includes a comprehensive assessment of the patient’s medical, functional, environmental, and psychosocial needs assessment. CCM provides management and support services provided by clinical staff, under the direction of a physician or qualified healthcare professional (QHP) to a patient residing at home or in a domiciliary, rest home, or assisted living facility. Patient’s must have two or more chronic continuous or episodic health conditions that:
- Are expected to last at least 12 months, or until death of the patient
- Place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
CCCM includes the above CCM requirements. CCCM services require a medical decision making of moderate or high complexity; and clinical staff care management services for at least 60 minutes under the direction of a physician or QHP during the calendar month. Only one physician or QHP may bill for CCM or CCCM during a calendar month
Psychiatric Collaborative Care Management (PCCM) & General Behavioral Health Integration Care Management (BHICM)
In order, to receive PCCM or BHICM services the patient must have a behavioral health or psychiatric condition, including substance use disorders, that, in the clinical judgment of the physician/QHP, warrants psychiatric services. The patient must have received a visit furnished by a physician/QHP no more than one-year prior to commencing PCCM or BHICM, such as an Evaluation and Management visit.
BHICM services can be billed once per month by the physician or QHP supervising the clinical staff rendering the BHICM. BHICM may not be billed during a calendar month when 99492, 99493, or 99494 are billed. Clinical staff time spent coordinating care with the emergency department may be reported using 99484, but time spent while the patient is inpatient or admitted to observation status may not be reported using 99484.
Transitional Care Management (TCM)
TCM services can be utilized for new or established patients whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting, partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to patient’s community setting. TCM commences upon the date of discharge and continues for the next 29 days. The physician or QHP takes responsibility for the member’s care post-discharge from the facility setting without a gap.
Physicians and QHPs may bill TCM services if they have primary responsibility for post-discharge care coordination. Only one health care professional may report TCM services for the 30-day post discharge period. The same health care professional may discharge the beneficiary from the hospital, report hospital or observation discharge services, and bill TCM services. However, the required face-to-face visit should not take place on the same day in which the discharge day management services are reported. Physicians/QHPs may not bill TCM services when they performed a surgery or procedure which has a post-operative global period. TCM services may not be reported by a physician/QHP within the same month as reporting:
- Care plan oversight services
- Home health or hospice supervision
- End-stage renal disease services
- Chronic care management services
- Prolonged evaluation and management services without direct patient contact
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
For more information reference the current edition of the CPT manual.
Created Care Management Services coding and billing guidelines.
Annual review completed.
Annual review completed. Added “payment integrity edits” to Limitation & Exclusions and added “Revision Effective Date:”