Since 2015, chronic care management (CCM) has been recognized by the Centers for Medicare and Medicaid Services (CMS) as a model of treating chronic care patients outside of the clinical office setting.

In the years since, some of the details and reimbursement amounts have changed. Yet today, CCM remains in place and is steadily gaining traction as an effective model for care and potential revenue stream) that’s often coupled with remote patient monitoring (RPM, or, in CMS terms, “remote physiologic monitoring”), to treat patients virtually.

But what is chronic care management, in a practical sense? And why should care leaders, administrators, and providers look to this model as a means to more effectively deliver long-term care, and possibly realize new revenue streams?

What Is Chronic Care Management (CCM)?

As defined by CMS — which sets the average reimbursements amounts in its yearly Physician Fee Schedule — chronic care management is one of four types of care management models:

Specifically designed to cover patient care that happens outside of the traditional clinical office setting, CCM covers services such as creating a care plan, managing that plan and any applicable medications, coordinating services, and communicating remotely (including over the phone, usually by a nurse).

Patients must have at least two chronic conditions to qualify for CCM. Chronic conditions are long-term illnesses that last from a year until the end of life, requiring active management and coordination. There’s a wide variety of chronic conditions, including cancer, chronic lung or chronic obstructive pulmonary disease (COPD), heart disease, hypertension, diabetes, stroke, Alzheimer’s disease, chronic kidney disease, hyperlipidemia and many more. You can get more info on the different types of chronic conditions here.

Chronic care management reimbursement details

In terms of CMS reimbursement, the latest CPT® Codes for CCM reimburse care coordination of patient services for multiple chronic conditions. This also includes coverage of the patient’s psychosocial needs and activities of daily living.

Chronic care management is an Evaluation & Management (E&M) service, and can therefore be billed not only by physicians, but also nurse specialists, nurse practitioners and physician assistants. CCM often falls under the purview of specialists like cardiologists, oncologists and pulmonologists. However, it should be noted that only one healthcare provider may receive reimbursement per code for a given patient.

As defined by the individual codes — G0506, 99490, 99491, 99489 and 99487 — this breaks down into separate reimbursement for assessment and care planning sessions, for the first 20 minutes and additional 20 minutes of clinical time (with a max of 60 minutes PPPM), or the first 30 minutes and additional 60 minutes PPPM for complex care. You can find more details, including average reimbursement amounts, here.

How chronic care management can be used with RPM

In the years since 2015, CMS has modified the reimbursement guidelines and amounts for chronic care management to reflect changes in the possibilities and prevalence of at-home care (a.k.a., telehealth), especially with the onset of Covid-19. For instance, a notable revision was made in 2020 to capture additional time for care beyond the mandated 20- and 30-minute segments (99439).

In 2019, CMS also introduced CPT codes for remote patient monitoring (RPM). Also sometimes known as remote physiological monitoring, RPM is designed to allow for reimbursement for the remote management of conditions that are often associated with chronic care, such as the continuous monitoring of vital signs. Like CCM, RPM codes have been expanded during the Covid-19 pandemic.

As such, some experts have advocated “coupling” RPM and CCM services in a way that takes full advantage of the reimbursement potential of both. And some enterprising providers have been doing just that, integrating CCM and RPM services to allow for new revenue streams for the management of long-lasting patient conditions. You can find an overview of the 2022 RPM codes here.

Yet whether the focus is CCM, RPM or both, creating a care plan is an important, challenging task. Everyone involved, including practice managers, physicians and specialists, and additional clinical staff, needs to be coordinated and working with established, well-considered protocols and routines for the model to be successful, and the full potential of reimbursement achieved.

Looking for help understanding how to use chronic care management in your organization?

If your organization is looking for ways to take advantage of new CCM reimbursement for chronic care management, we may be able to help! Contact us here to connect to a CareSimple specialist. 

If you’re looking for details on the specific CPT Codes for CCM, RPM, RTM, and others, we encourage you to download our handy Reimbursement Tree for a convenient and up-to-date one-page summary.