Chronic care management codes: How CCM, PCM, and RPM codes compare

 

On Nov. 15, 2019, CMS finalized the CY 2020 Medicare Fee Schedule (MFS). The 2020 MFS revises current chronic care management (CCM) and remote physiologic monitoring (RPM) reimbursement practices and creates a new care management reimbursement program for a single chronic condition: principle care management (PCM).

These three categories fall under CMS’s umbrella of care management services and work to improve the treatment of chronic conditions. 

Here’s a quick look at each category:

 

Chronic Care Management

2020 Medicare Reimbursable Codes: 99487, 99489*, 99490, G2058*, 99491

With CCM, the clinician provides or oversees the management and/or coordination of services for multiple chronic conditions, psychosocial needs and activities of daily living. According to the AMA, clinicians perform “services include establishing, implementing, revising, or monitoring the 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”.** These codes are geared toward primary care physicians (PCPs) but can be billed by any physician or qualified healthcare professional who fulfills the code requirements. 

There are two subsets of CCM codes based on case severity: non-complex and complex. Complex CCM codes have a longer time requirement and higher complexity of decision-making than non-complex codes. In the CY 2020 MFS, CMS introduced add-on code (G2058) for an additional 20 minutes of management of non-complex CCM, and they modified one of the criteria for complex CCM codes to align more closely with the criteria for non-complex CCM codes.

 

Principle Care Management

2020 Medicare Reimbursable Codes: G2064, G2065

Clinicians who bill for PCM play a similar role to those who bill CCM codes with one caveat: they only perform or oversee management for a single chronic condition. CMS created these codes to supplement current reimbursement and to encourage holistic care management of chronic conditions. These codes are geared toward specialists who care for a patient’s singular condition (e.g., a pulmonologist who treats a patient’s COPD) but can be billed by any physician or qualified healthcare professional (QHP) who fulfills the code requirements. These codes have the same billing qualifications as CCM codes.

 

Remote Physiologic Monitoring

2020 Medicare Reimbursable Codes: 99453, 99454, 99457, 99458*, 99091

Remote physiologic monitoring is a clinical service that uses technology to enable monitoring of patients’ physiologic data outside of conventional clinical settings. The provider can be reimbursed for the onboarding and patient education on the program, the device supply, patient monitoring and management of their condition. In CY 2020, CMS will reimburse for code 99458, a new add-on code which reimburses for an additional 20 minutes of remote physiologic treatment management.

*These codes are bundled add-on codes and therefore cannot be billed separate from their respective base code.

Medicare Advantage plans by default will reimburse on these codes; some states and commercial payers also reimburse on them. Healthcare providers (HCPs) or health systems should check with their state Medicaid programs and private payers for specific reimbursement rules and requirements, as they do vary. In addition, CMS releases new regulation and language regarding their reimbursement policies periodically in the Federal Register. Practices may benefit from staying up to date on these releases.

To learn more, watch a recording of our webinar on RPM reimbursement.

For more information on our clinical programs, visit www.propellerhealth.com/healthcare-providers or email us at [email protected].

CPT is a registered trademark of the American Medical Association. Copyright 2020, American Medical Association. All rights reserved.

Disclaimer: The opinions shared on this webpage do not reflect the opinions of any regulator, company, or association. It is the sole responsibility of the HCP or healthcare organization to determine which billing codes are appropriate for which services. If you have a regulatory or legal question, please consult the proper authority, association, or an attorney.  

**For additional coding guidelines and billing exclusions visit the “American Medical Association CPT Professional 2020” accessed Dec 2019 from https://commerce.ama-assn.org/store/ui/catalog/productDetail?product_id=prod2950002