Care Management Services

Policy No: 122
Originally Created: 03/01/2016
Section: Administrative
Last Reviewed: 11/01/2024
Last Revised: 11/01/2024
Approved: 11/14/2024
Effective: 12/01/2024
Policy Applies To: Group and Individual & Medicare Advantage

This policy applies to all contracted physicians, other health care professionals, hospitals, and other facilities.

Advance Care Planning (ACP) – Advance care planning is a process that supports members and helps them understand possible, future health choices, based on their own goals and values. With ACP, members reflect on their healthcare choices; communicate these with those close to them and their health care providers; and create a plan for future healthcare situations should they become unable to make their own medical decisions.

Advance Directives (AD) – An advance directive is the documented plan created by members for future healthcare. This plan provides instructions about the choices they prefer for future healthcare and/or appoints another person or persons who would make their healthcare decisions, if they were unable to communicate these decisions themselves.

Chronic Care Management (CCM) – Chronic Care Management is a specialized healthcare service (i.e., care coordination that is outside of the regular office visit) that is designed to provide comprehensive support and coordination for individuals living with multiple (two or more) chronic health conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.

Clinical Staff – A person (Medical Assistant, Licensed Practical Nurse, Registered Nurse, etc.,) who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.

Goals of Care (GOC) – Conversation(s) to elicit and understand member goals, integrate them into the current medical context and recommend the course of action that best aligns with those goals and wishes. This is not a one-time discussion but an interactive process whereby a clinician identifies a patient’s understanding of their medical issues, provides them with a framework to assess their goals and allows them time to reflect and discuss with family and caregivers. This process allows patients to change their goals and values over time as their health status changes but always requires clinician guidance and recommendations about how a plan of care helps or does not help a patient achieve those goals.

Incident To – Services that are furnished incident to physician professional services in the physician’s office (i.e., separate office suite or within an institution) or in a member’s home.

Physician’s Orders for Life Sustaining Treatment (POLST) – A form for individuals used to communicate decisions regarding GOC, for treatment of complications from serious illness or advanced frailty. The POLST program documents an individual’s healthcare decisions as a medical order, which can be used throughout the healthcare spectrum.

When criteria are met, our health plan reimburses for care management services.

ACP conversations and GOC conversations are reimbursable using ACP Current Procedural Terminology (CPT®) codes. ACP is a Care Gap reimbursable for Quality Incentive Program (QIP). Providers such as Hospitals, Physicians (MD/DO), and Qualified health care professionals (Clinical Nurse Specialists, Nurse Practitioners, Physician Assistants/Physician Associates, etc.) may bill for ACP services. All other providers (social work, psychology, chaplains) may not report codes independently. When ACP is performed as “incident to” billing, other team members (e.g., SW, RN) may perform ACP in collaboration with a qualified provider who corroborates wishes.

There are no place of service limitations on the ACP codes for qualified providers. ACP codes may be billed by qualified providers in any clinical setting:

• Inpatient, Emergency Department, Observation Area
• Office or Clinic
• Home or 'domicile' (e.g., adult foster care, assisted living, group home)
• Skilled Nursing Facility
• Long-term care (assisted living)

• Hospice (must be able to bill Medicare Part B) Exception: Medicare doesn’t allow 99497/99498 to be billed on the same date of service as certain critical care services including neonatal and pediatric critical care.

Our Health Plan reimburses providers for conducting and documenting GOC conversations, CPT 99497, or 99498.

Reimbursable activities for ACP codes include, but are not limited to:

• Education on ACP documents, such as a medical power of attorney or living will
• Discussion of personal preferences and/or completion of ACP documents
• Education on POLST form
• Discussion of personal preferences and/or completion of POLST form

• GOC conversations

Codes/Descriptions:
Requirements for CPT Code 99497:

• ACP, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed).
• Provided by the physician or other qualified health care professional.
• First 30 minutes face-to-face with the patient, family member(s), and/or surrogate (minimum of 16 minutes documented).

• As stated in the CPT code description, completion of an advance directive is only required "when performed". It is not an overall requirement for billing ACP services.

Requirements for CPT Code 99498 (Add on code):

• Each additional 30 minutes face-to-face with the patient, family member(s), and/or surrogate (minimum of 16 minutes past the first 30 minutes documented).

• Listed separately in addition to code for primary procedure.

Non-physicians must legally be authorized and qualified to provide ACP in the state in which the services are furnished.

Health Plan specific tracking CPT II codes: To be used if completing ACP separately from an annual wellness visit (AWV) to complete the ACP conversation, track/close the ACP gap but avoid a member copayment.

1123F: ACP discussed and documented – advance care plan or surrogate decision-maker documented in medical record

1124F: ACP discussed and documented in medical record – Patient didn’t wish to or was unable to provide an advance care plan or name a surrogate decision maker

1158F: ACP discussed and documented in the medical record

The following documentation must be submitted to meet the minimum requirements for ACP reimbursement:

• The names of health care participants.
• The name of the patient, family, or representative.
  • If patient cannot participate in the conversation, please state the reason why they are absent.
• The voluntary nature of the conversation.
• The topics discussed, summary of discussion, and/or decisions made.
• Any documents discussed and completed, such as medical power of attorney or POLST form.
• The start and end time of the conversation.

• Whether the conversation was in-person or virtual.

Additional documentation may be requested as needed.

Our Health Plan reimburses providers for conducting and documenting CCM billing codes.

CPT codes used to report CCM services:

• 99490 for the first 20-minutes of non-complex CCM provided by clinical staff to coordinate care across providers and support patient accountability.
  • Reported once per calendar month.
• 99439 is reported for each additional 20 minutes of non-complex CCM (replaced G2058).
  • Cannot be billed more than twice per calendar month.
• 99487 for the first 60-minutes of complex CCM provided by clinical staff to revise or establish comprehensive care plan that involves moderate- to high-complexity medical decision making.
  • Reported once per calendar month.
• 99489 is reported for each additional 30 minutes of complex CCM services.
  • Reported once per calendar month.
  • Cannot be billed with CPT code 99490.
• 99491 for at least 30 minutes of CCM services provided personally by a physician or other qualified health care professional.
  • Reported once per calendar month.

• 99437 is reported for each additional 30 minutes of CCM services.

  • Reported once per calendar month.

CCM care planning may be face-to-face and/or non-face-to-face, but the time spent doing the CCM care planning must not already be reflected in the CCM initiating visit itself if the physician reports an Evaluation and Management (E&M) service on the same day.

Additional requirements include, but are not limited to, the following:

• Only one clinical staff can bill and receive reimbursement for CCM services once per calendar month. Specifically, the member would be classified as eligible to receive CCM services for either complex (99487/99489), non-complex (99490/99439), or those provided personally by a physician or other qualified health care professional (99491).

Add-On Code

• G0506 Comprehensive assessment of and care planning for patients requiring CCM services (list separately in addition to primary monthly care management service)

  • This is an add-on code to be used with another E&M service (the CCM initiating Annual Wellness Visit/Initial Preventive Physical Examination AWV/IPPE or qualifying face-to-face E&M visit).
  • It cannot be an add-on code for the behavioral health initiative (BHI) initiating visit or BHI services.
  • It is meant to account specifically for additional work of the billing provider in:
    • Personally, performing a face-to-face assessment
    • Personally, performing CCM care planning
  • Only billable one time, at the onset of CCM services

Required elements for billing 99490/99439:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.
• Chronic conditions place the member at significant risk of death, acute exacerbation/decompensation, or functional decline.
• Comprehensive care plan established, implemented, revised, or monitored.
• 99490 is reported for the first 20 minutes of clinical staff time, directed by a physician or other qualified health care professional for CCM services and is allowed once per calendar month.
  • Do not report if less than 20 minutes.

• 99439 is to be listed separately in addition to the primary procedure code (99490) and is to only be billed for each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional.

  • This code cannot be reported more than twice per calendar month.

Required elements for billing 99487 and 99489:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.
• Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
• Comprehensive care plan established, implemented, revised, or monitored.
• Medical decision-making is of moderate or high complexity.
• 99487 is reported for the first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, for complex CCM services.
  • Do not report if less than 60 minutes.

• 99489 is to be listed separately in addition to the primary procedure code (99487) and is to be billed for each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional.

  • Do not report if less than 30 minutes.

Required elements for billing 99491:

• CCM services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, 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.

CCM Services for Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs):

• G0511, rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for CCM services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month.

• G0512, Rural health clinic or federally qualified health center (RHC or FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month.

Principal Care Management (PCM):

Centers for Medicare & Medicaid Services (CMS) created a set of codes that can be billed to describe care management services for ONE complex chronic condition. A qualifying condition is expected to last at least 3 months, places the patient at risk for hospitalization, and/or places the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

• 99424 for principal care management services provided personally by a physician or other qualified health care professional for a single high-risk disease, with one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute.
  • 99425 for principal care management services, provided personally by a physician or other qualified health care professional for a single high-risk disease with one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk if hospitalization, acute. exacerbation/decompensation, functional decline, or death; each additional 30 minutes.

• 99426 for principal care management services clinical staff time directed by physician or other qualified health care professional for a single high-risk disease, with one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk if hospitalization, acute exacerbation/decompensation, functional decline, or death; first 30 minutes.

  • 99427 for principal care management services clinical staff time directed by physician or other qualified health care professional for a single high-risk disease, with the following required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk if hospitalization, acute exacerbation/decompensation, functional decline, or death; each additional 30 minutes.

Qualified Providers/Facilities include:

• Physicians
• Certified Nurse Midwives (CNM)
• Clinical Nurse Specialists (CNS)
• Nurse Practitioners (NP)
• Physician Assistants/Physician Associates (PA)
• Federally Qualified Health Clinics (FQHCs) and Rural Health Clinics (RHCs)

• Hospitals (including critical access hospitals)

"Incident to" billing may be utilized for CCM services. CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner), subject to applicable state law, licensure, and scope of practice.

• Clinical staff are to follow the “incident to” billing requirements as defined by CMS.

Proper modifier 25 coding and billing guidelines, in addition to meeting medical necessity criteria, must be followed if billing for both E&M and CCM services on the same day for the same member by the same clinical staff. If coding and billing requirements for modifier 25 are not met, clinical staff time for CCM services cannot be counted on the same day as the E&M service.

Clinical staff are to follow the CMS CCM Scope of Service Elements and Billing Requirements. Information on these requirements is located on the CMS webpage Connected Care: The CCM Resource under Health Care Professional Resources.

Additional Billing Requirements:

CCM services that cannot be billed during the same service period, except as previously noted by CMS, are:

• 90951-90970 (End Stage Renal Disease services)
• In the postoperative period of a reported surgery
• 93792 and 93793 (Anticoagulant training/management)
• 98960-98962 (Education and training)
• 98966-98968 (Telephone assessment and management services
• 99071 and 99078 (Education supplies/training)
• 99080 (Preparation of special reports)
• 99091 (Remote patient monitoring)
• 99358 and 99359 (Prolonged services, without direct patient contact)
• 99366-99368 (Medical team conferences)
• 99421-99423 (Online digital E&M service)

• 99441-99443 (Telephone services)

CCM services that cannot be billed during the same service period with 99439 and 99490, except as previously noted by CMS, are:

• 98970-98972 (Online digital assessment and management)

• 99605-99607 (Medication therapy services)

CCM services that cannot be billed during the same service period with 99487 and 99489, except as previously noted by CMS, are:

• 99424 and 99425 (Principal care management)
• 99374, 99375 and 99377-99380 (Supervision of patient care, without direct patient contact; home health, hospice, nursing facility)

• 99605-99607 (Medication therapy management services)

Do not report 99491 with 99495-99496 (transitional care management services)

For psychiatric care management services, see 99492-99494

CCM services will not be reimbursed:

• For individuals located outside the United States

Telehealth/Telemedicine Services

• Visit the CMS Telemedicine/Telehealth website on coding and billing requirements.

CCM Services may be billed under the Physician Fee Schedule (PFS) or Outpatient Prospective Payment System (OPPS).

Facility Billing Rules

• Refer to the CMS requirements on Connected Care: The Chronic Care Management Resource webpage for scope of service elements furnished to hospital outpatients under the OPPS.
• The time spent providing CCM services to the member while he/she is not inpatient can be counted towards the minimum minutes of service time that is required to bill for that month.
• Hospitals can bill CCM services only when furnished to a member who has been either admitted to the hospital as an inpatient or has been registered outpatient of the hospital within the last 12 months and for whom the hospital furnished therapeutic services.
• If the place of service for CCM becomes the hospital outpatient department, it is assumed that the member has established a relationship with the hospital for CCM services.
• A provider-based outpatient department of a hospital is part of the hospital and therefore may bill for CCM services furnished to eligible members, provided it meets all applicable requirements. A hospital-owned practice that is not provider-based to a hospital is not part of the hospital and, therefore, not eligible to bill for services under the OPPS; however, the clinical staff practicing in the hospital-owned practice may bill under the CMS Physician Fee Schedule for CCM services furnished to eligible members, provided all billing requirements are met.
• When a clinical staff furnishes CCM services in a hospital outpatient department to an eligible member, the clinical staff may bill CCM services using place of service 22 (outpatient hospital). Reimbursement to the clinical staff will be made at the CMS Physician Fee Schedule facility rate.

• As only one clinical staff is allowed to bill for CCM services during a calendar month service period, accordingly, only one hospital is allowed to bill and be paid for CCM services during a calendar month service period.

Claims received for CCM Services are processed based on the date the claim is received.

Advance Care Planning: MLN Fact Sheet

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Virtual Care