CCM Under the Microscope: Are Your Providers Documentation-Ready?
Written by: Christine Hall, CHC, CPC , CDEO, CPB, CPMA, CRC, CEMC, CPC-I
Chronic Care Management (CCM) services are getting extra attention from Medicare Administrative Contractors (MACs) as part of their Target, Probe, and Educate (TPE) program. They are closely reviewing CCM claims for possible misuse, which could lead to fraud and abuse allegations under the False Claims Act by the Department of Justice. Understanding the requirements to perform these beneficial services could be the difference between risk and opportunity, as proper documentation and billing are essential to avoid serious legal consequences.
CCM programs have been proven to reduce hospital readmissions and emergency department visits by helping patients with ongoing health problems stay on track with their treatment plans. The Center for Medicare and Medicaid Services (CMS) found that patients in CCM programs had nearly 5% fewer hospital stays and 2.3% fewer visits to the emergency room. CMS also reported that hospitals using CCM programs saw a 20-30% drop in readmission rates for patients with chronic diseases. These improvements are linked to the increased use of CCM services.
CCM helps patients follow their treatment plans, improve their chronic condition management through medications, and make healthy lifestyle changes. This leads to fewer complications and better overall health. Patients receive regular check-ins, personalized care plans, and ongoing support to keep them engaged and informed.
What is Chronic Care Management (CCM)?
CCM provides structured support for patients with two or more chronic conditions, which are defined as lasting a year or more and requiring ongoing medical attention or limiting daily activities. By offering individualized care plans, medication management support, and ongoing education, CCM helps patients manage their health more effectively at home, reducing hospitalizations and preventing complications.
CCM requires a Patient-Specific Personalized Care Plan:
- Individualized Needs: Each CCM care plan is created to meet the patient’s specific health needs, considering their medical history, lifestyle, and preferences.
- Living Documents: CCM care plans are not one-time documents. They are reviewed and updated regularly based on the patient’s progress and changing needs.
- Goal Setting: CCM care plans include specific health goals, such as managing blood pressure, maintaining a healthy diet, or keeping blood sugar levels under control.
CCM empowers patients and caregivers by providing educational resources and regular check-ins to monitor progress. This ultimately improves self-management and overall health outcomes. By connecting patients to community resources, CCM helps them overcome these barriers and better manage their conditions.
CCM CPT® codes like 99490 provide separate payments for non-face-to-face services, reimbursing practices for time spent managing patient care between visits, such as care coordination and communication. These codes compensate for the non-traditional time and effort required to manage patients with multiple chronic conditions.
Requirements for Billing Chronic Care Management (CCM)
Eligible patients must have two or more chronic conditions expected to last at least 12 months or until the patient’s death. Chronic conditions require ongoing medical attention or limit activities of daily living or both, posing a significant risk of exacerbation or functional decline in the near term.
For example, chronic conditions include diabetes, cardiovascular disease, dementia, COPD, and cancer.
| CPT® Code | Description | Time | Performed by: |
| 99490 | Time per month, directed by a physician or qualified healthcare professional, for patients with two or more chronic conditions expected to last 12 months or more, posing significant health risks and requiring a comprehensive care plan. | 20 | Clinical Staff |
| 99439+ | each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month | 20 | Clinical Staff |
| 99491 | Time per month, by a physician or other qualified health care professional, for patients with two or more chronic conditions expected to last 12 months or more, posing significant health risks and requiring a comprehensive care plan. | 30 | Physician or QHP (NP/PA) |
| 99437+ | each additional 30 minutes of a physician or other qualified health care professional, per calendar month | 30 | Physician or QHP (NP/PA) |
| 99487 | Time per month, directed by a physician or qualified healthcare professional, for patients with two or more chronic conditions expected to last 12 months or more, posing significant health risks, moderate or high MDM, and requiring a comprehensive care plan. | 60 | Clinical Staff |
| 99489+ | each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month | 30 | Clinical Staff |
Before CCM services can start, a provider must initiate a visit with the patient within the past year. This visit can be part of a regular office visit, an Annual Wellness Visit (AWV), or an Initial Preventive Physical Examination (IPPE). During this visit, the provider explains the CCM program, obtains the patient’s verbal or written consent, and develops the initial care plan.
The consent should include information about the cost-sharing requirement, the right to discontinue services at any time, and the fact that only one provider can bill for monthly CCM services.
Supportive Documentation for CCM Billing
CCM emphasizes a comprehensive approach to patient care, requiring each individual’s creation, implementation, and maintenance of detailed care plans.
CCM can utilize clinical staff, and their work is subject to CMS’s “incident to” guidelines. This means it requires general supervision by the billing practitioner and meticulous documentation of services performed. The billing practitioner must remain actively involved in treatment for the clinical staff’s services to be considered “incident to” or incidental to the care plan.
All CCM activities must be documented in the patient’s medical record. This includes care coordination, patient education, medication management, and follow-up calls. The documentation should show what was done, how much time was spent, and any outcomes or recommendations.
Example:
A patient with uncontrolled hypertension and diabetes that is not well managed is enrolled in CCM. The physician creates a care plan with a medication schedule and dietary advice. Clinical staff then follow up weekly to check on medication side effects and diet adherence, provide education on managing blood pressure and blood sugar, and review lab results. All activities are documented, and the time spent on each activity is tracked for billing.
About the Author: Christine Hall & Stirling Global Solutions
Christine Hall has 30+ years of health administration management experience and a degree in sociology. She is certified in Healthcare Compliance (CHC), a Certified Professional Coder, Biller, Auditor, Risk Adjustment Coder, a specialty coder in Evaluation and Management, and a certified instructor.
Stirling Global Solutions provides Chronic Care Management (CCM) education and resources. Follow us for updates on CCM service requirements. Contact NAMAS or the CMS website for more information on CCM services and billing guidelines.
