Medicare Chronic Care Management: Who Can Bill for Service?

As of Jan. 1, 2015, Medicare pays separately for chronic care management (CCM).

Medicare pays under CPT code 99490 for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.

Who can bill for CCM service? Physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives can bill for this service, and clinical staff as defined by Current Procedural Terminology (CPT) can furnish the service "incident to" any of these professionals. In addition, practices can use clinical staff (such as a case management company) outside the practice to provide CCM services incident to the billing physician/practitioner.

CPT defines a clinical staff member as "a person 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."

The Centers for Medicare and Medicaid Services (CMS) provided an exception under Medicare's incident to rules that permits clinical staff to provide the CCM service incident to the services of the billing physician/practitioner under the general supervision  (rather than direct supervision) of a physician/practitioner. "General supervision" means the service is furnished under the billing physician/practitioner's overall direction and control, but that person could be on call and not necessarily on site in the office.

CMS speculates that in most cases, practices will bill for CCM services that clinical staff provide incident to the billing physician/practitioner. A few tips:

  • Be sure you understand Medicare's billing criteria for incident to services.
  • Some clinical staff may not normally track and document their activity that doesn't involve face-to-face care. You might develop a work log to track and document the time clinical staff   and physicians/practitioners spend on each patient's CCM-related services. If the time adds up to at least 20 minutes in a calendar month (per CPT code 99490), you can bill for the CCM service for that patient for that month.
  • Remember, you cannot count nonclinical staff time toward the 20 minutes per month, although these staff members may help facilitate CCM services.
  • Note also that only one billing physician/practitioner may be paid for the CCM service for a patient for a given calendar month.

For more information about billing for the CCM service, see CMS' guide, Chronic Care Management Services. In addition, CMS has released FAQs on this topic, and the American College of Physicians has created a CCM toolkit.

If you have questions about coding or billing, contact the TMA Knowledge Center at (800) 880-7955 to reach a TMA expert. Visit TMA's Medicare Resource Center for Medicare information and resources. See also this e-tip about Medicare's requirements for using an electronic health record for some components of CCM.

Published May 27, 2015

TMA Practice E-Tips main page

Last Updated On

May 13, 2016

Originally Published On

May 27, 2015

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