Care Management Services are for the support and management activities delivered either directly by a physician or qualified healthcare professional (QHCP) under their supervision. These services are provided to patients living at home, in a domiciliary setting, a rest home, or an assisted living facility.
Per Center for Medicare and Medicaid Services (CMS) guidelines, before chronic care management (CCM) services can start, CMS requires an initiating visit for new patients or patients who have not seen the provider within the previous 12 months. The physician or QHCP may conduct the initiating visit during a comprehensive face-to-face evaluation and management (E/M) visit, annual wellness visit (AWV), or initial preventive physical exam (IPPE). If the physician or QHCP did not discuss CCM during an E/M visit, AWV, or IPPE, is not considered the initiating visit. A face-to-face initiating visit is not part of CCM and can be separately billed. If the physician or QHCP personally provides extensive assessment and care planning outside the usual effort described by the initiating visit and CCM codes, they may also bill HCPCS code G0506 once, as part of an initiating visit.
The physician or QHCP who submits claims for these services is responsible for delivering or overseeing the management and/or coordination of the care, which includes:
· Establishing, implementing, revising, or monitoring the care plan.
· Coordinating the care of other professionals and agencies.
· Educating the patient or care giver about the patient’s condition(s), care plan and prognosis.
There are three categories for general care management services: chronic, complex, and principal care management, and the requirements for each are outlined below.
CCM Services:
· Medical and/psychosocial needs of the patient require a care plan to be established, implemented, revised, or monitored,
· requires two or more chronic continuous or episodic health conditions which are expected to last for at least the next twelve months or until the death of the patient,
· these chronic conditions put the patient at significant risk of death, acute exacerbation/decomposition, or functional decline
Code 99490: to report the first 20 minutes of clinical staff time directed by the physician, or other qualified healthcare professional, per calendar month
· 99439: each additional 20 minute of clinical staff time directed by the physician or other qualified healthcare professional per month (list separately in addition to the primary code)
· Code 99491: to report the first 30 minutes of services personally provided by the physician or other qualified healthcare professional per month
· 99437: each additional 30 minutes of service personally provided by the physician or other qualified healthcare professional, per month
Complex CCM Services:
There are a couple significant differences between CCM services and complex CCM services, which are highlighted in bold below.
· Complex CCM services require at least 60 minutes of clinical staff time, under the direction of a physician or QHCP,
· medical and/psychosocial needs of the patient require a care plan to be established, implemented, revised, or monitored,
· requires two or more chronic continuous or episodic health conditions which are expected to last for at least the next twelve months or until the death of the patient,
· the chronic conditions put the patient at significant risk of death, acute exacerbation/decomposition, or functional decline,
· moderate or high complexity of medical decision making
Code 99487: to report the first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month
· 99489: each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per month
NOTE: If the physician performs the clinical staff activities, their time may be counted toward the required clinical staff time to meet the code’s elements
Principal Care Management Services:
· Focus on a single complex (high-risk) chronic condition expected to last at least 3 months that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death,
· requires a disease specific care plan to be established, implemented, revised, or monitored.
· the condition requires frequent adjustments to medication regime and/or the management of the condition is unusually complex due to comorbidities,
· ongoing communication and care coordination between relevant practitioners furnishing care
Code 99424: to report the first 30 minutes provided by the physician or other qualified health care professional, per calendar month
· 99425: each additional 30 minutes provided by the physician or other qualified health care professional per calendar month.
Code 99426: to report the first 30 minutes of clinical staff time directed by the physician or other qualified health care provider
· 99427: each additional 30 minutes of clinical staff time directed by the physician or other qualified health care provider.
What are some common billing and compliance issues for CCM services?
· Patient ineligibility
· Lack of patient consent
· Inadequate documentation
· Single diagnosis on the claim line
· Condition does not meet criteria for chronic illness/disease
· Billing for ineligible practitioners or staff
· Inflating time spent providing CCM Services
· Billing for non-complex and complex CCM in the same month
If claims are paid for CCM services with a single diagnosis, post payment review may be recommended to ensure documentation reflects the complexity of care and is sufficient to support the level of service billed.
How can Fraud Scope assist your health plan with identifying issues with CCM services?
Fraud Scope’s AI detector models and query toolkit can assist your health plan in identifying the physicians or QHCP’s with the highest volume of claim lines and payments for CCM services.
AI detectors
Fraud Scope’s pattern-based detection models, such as Outlier Abuse, Suspicious Trends, and Time Behavior identify outlier utilization for CCM services, such as:
· Physicians or QHCP’s with higher volume of CCM services compared to their peers
· Recent peaks or increasing trends for CCM services
· Cookie-cutter diagnosis codes across the bulk of the claim lines
Aggregate utilization
Fraud Scope users can quick identify which physicians or QHCP’s have the highest utilization for CCM services using the following Query, Professional, Aggregates, [Rendering or Billing], Code Type = Procedure code search
Procedure Code = These, Enter and choose – 99490, 99439, 99491, 99437, 99487, 99489
Provider Payment Received = Within this range – Minimum = 1
Claim line details
Fraud Scope users can identify CCM services with a single diagnosis code using the following filters and criteria in a Query, Professional, Lines search
Procedure Code = These, Enter and choose – 99490, 99439, 99491, 99437, 99487, 99489
Diagnosis Code = Custom Editor – Copy/paste the following into the text box ** NOT @
The ‘** NOT @’ criteria will return claim lines with only a single diagnosis
Total Paid Amount = Within this range – Minimum = 1
References:
- Medicare Learning Network
- Center for Medicare and Medicaid Services (Home – Centers for Medicare & Medicaid Services | CMS )
https://www.cms.gov/files/document/chronic-care-management-faqs.pdf
- American Medical Association (AMA) version of the 2025 CPT coding manual Pages 54-60