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Chronic Care Management: Coding and Billing Criteria

Chronic Care Management: Coding and Billing Criteria

Physicians may spend significant time managing care for patients with chronic health conditions. In 2015, CPT® introduced a code to report these services. To gain payment, both the patient and the documented care provided must meet extensive conditions.


Per the AMA's CPT Assistant (October 2014):

Care management services are provided by clinical staff, under the direction of a physician or other qualified healthcare professional. These management and support services are provided to patients who reside at home or in a domiciliary, rest home, or assisted living facility, and may include establishing, implementing, revising, or monitoring the patient's care plan; coordinating the care of other professionals and agencies; and educating the patient or caregiver about the patient's condition, care plan, and prognosis.

The physician or other qualified healthcare professional provides or oversees the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs, and instrumental and basic activities of daily living.


The basic requirements to report 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare 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 are defined within the code descriptor:

1. The services are time-based, and are billed once per calendar month.

Time may be non-contiguous and is totaled over the course of a calendar month. Care management time includes direct patient contact and non-face-to-face time dedicated to the patient's care. CPT Assistant (October 2014) stipulates that care management time may entail:

Time spent by the clinical staff in communicating either face-to-face or non-face-to-face with the patient and/or family, caregivers, other professionals, and agencies.

Time spent revising, documenting, and implementing the care plan, and/or teaching self-management.

Only time spent by the clinical staff of the reporting professional is counted toward the care management services time. When two or more clinical staff members are meeting about the patient, only count the time of one clinical staff member. Clinical staff time is not counted on the date of the first visit or on a day when the physician or qualified healthcare professional reports an E&M service (office or other outpatient services, codes 99201-99215; domiciliary, rest home services, codes 99324-99337; and home services, codes 99341-99350).

Care management activities performed by clinical staff typically include:

Communication and engagement with patient, family members, guardian or caretaker, surrogate decision makers, and/or other professionals regarding aspects of care;

Communication with home health agencies and other community services utilized by the patient;

Collection of health outcomes data and registry documentation;

Patient and/or family/caregiver education to support self-management independent living and activities of daily living;

Assessment and support for treatment regimen adherence and medication management;

Identification of available community and health resources;

Facilitating access to care and services needed by the patient and/or family;

Management of care transitions not reported as part of transitional care management (codes 99495, 99496);

Ongoing review of patient status, including review of laboratory and other studies not reported as part of an E&M service as noted above; and

Development, communication, and maintenance of a comprehensive care plan.

Only one provider (the provider assuming the care management of the patient) may report 99490, in a given month.


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