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Chronic Care Management: 6 Tips for Documentation Success


As a medical billing company CEO,  I have heard lots of physicians and practice managers complain about time spent on non-billable services, like chronic care management. “My staff and I spend an awful amount of time helping patients over the phone; is there any way I can get paid for that?”

Physicians also want to know if they can be paid for services provided in between patient visits, such as completing forms, medication refills, and telephone consults. My response has always been “no”; there was no reliable way to get paid for these types of services. Now however, some of that has changed with Medicare’s new willingness to pay for Chronic Care Management Code 99490.

In this blog post, I’ll go over some rules and tips on how to document  for this service.

Take Advantage of the Reimbursement Opportunity

According to the CDC, one-third of the U.S. population has at least one chronic disease, such as cancer, asthma, diabetes or heart disease. Chances are good that we, or people we love, have experienced the challenges of coordinating care for these complex conditions.

CMS has a list of about 22 things the practice needs to do to comply, including engaging with each patient over the phone for 20 minutes each month to coordinate care. It doesn’t have to be one phone call, but could be a five-minute phone call each week, for example.

On these calls, clinicians find out what’s going on with patients and help them figure out what care they need and where they can get it. In return, CMS will pay about $40 per member, per month.

CMS Says

CPT code 99490 is defined as: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care 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.

What constitutes a Chronic Condition?

According to the CDC, 66% of Medicare patients had two or more chronic conditions in 2015. Chronic conditions include:

  • Alzheimer’s and related dementia
  • Arthritis
  • Asthma
  • Atrial Fibrillation
  • Autism
  • Cancer
  • COPD
  • Depression
  • Diabetes
  • Heart Failure
  • Hypertension
  • Ischemic Heart Disease
  • Osteoporosis

Although this is not the complete list, practices see many patients with two or more of these diseases. So, it’s safe to say many medical practices have a large population of patients eligible for this service.

Key CCM Definitions:

Clinical Staff:  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.

Examples Include:

  • Medical Assistants
  • Nurses
  • Therapists

Directed by a Physician: CMS allows a physician to bill for this service so long as the service is provided under his/her general supervision. This means the physician is present and/or accessible during the time of service, and is able to guide the care. No direct contact between the physician and the patient is needed to bill this code.

Comprehensive Care Plan: according to CMS, a Comprehensive Care Plan includes the following:

  • Problem list;
  • Expected outcome and prognosis;
  • Measurable treatment goals;
  • Symptom management;
  • Planned interventions and identification of the individuals responsible for each intervention;
  • Medication management;
  • Community/social services ordered;
  • A description of how services of agencies and specialists outside the practice will be directed/coordinated; and
  • Schedule for periodic review and, when applicable, revision of the care plan.

These items should be documented in the patient’s chart prior to billing for the CCM code.

6 Tips for Documentation Success

1) Medicare requires that the patient understands and agrees to the chronic care management services before they are offered and billed. It may be best to draft a basic letter that the physician can review with the patient during their face-to-face visit prior to billing for the CCM. This letter should be signed by the patient and recorded in the patient’s record.

This letter should include:

  • An explanation of the CCM and its availability
  • An explanation that the patient can revoke the service
  • A portion explaining that only one provider can bill for this service for each patient
  • An explanation on what information may be shared between physicians

You can find tools & templates for CCM in the American College of Physicians CCM toolkit  (free) and the CCM Toolkit from the American Academy of Family Physicians ($69 for AAFP members).

2)  Medicare requires that an Annual Well Visit or Comprehensive Evaluation and Management code be billed prior to the CCM. During this first visit, document the discussion with the patient described above, his/her acceptance or denial, and the care plan that the CCM will follow.

3)  Consider building a template in your EMR/EHR that you or your clinical staff can use to document each CCM service. This template should copy over some elements of the care plan documented during the initial face-to-face visit including: basic demographic information, medication and allergy info, the patient’s consent to the service, and clinical summaries that can be shared with other physicians.

4) Set up a system that can keep track of time spent on non-face-to-face services provided, including:

  • Phone calls and email communication with patient.
  • Time spent coordinating care (by phone or other electronic communication) with other clinicians, facilities, community resources, and caregivers.
  • Time spent on prescription management and medication reconciliation.

5)   When billing for CCM make the date of service range the calendar month in which you are billing, for example – 01/01/2016-01/31/2016.

6)  A practice can insource or outsource the delivery of CCM services for its patients. In either case, your practice will need to establish a consistent system of documentation based on your own physical, staffing, and EHR configurations.

Once your tools and processes are set up, documentation of these services will go smoothly.

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What tips or tools have you implemented to make the most of your Chronic Care Management program?

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22 thoughts on “Chronic Care Management: 6 Tips for Documentation Success”

  1. blank

    A lot of useful tips. I have to take a lot of measures to manage my chronic asthma, including watching the outdoor conditions. I even monitor the air quality on apps like IQair and Climacell. These tips will come in handy to get the documentation part right.

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    Great content! CCM can be SO complicated when it comes to compliance for mom and pop clinics! thank you!

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    Hi, I’m trying to work with CCM but I’ still not completely sure how to do it; any help will be really appreciated. When it says a comprehensive care plan has to be created… Is this care plan like the nursing care plan? Does someone has an example of a care plan to share?

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    Please assist….we perform split billing meaning we bill for the facility or hospital and for the physicians. My question is can we bill for 99490 on our UB claim and on our HCFA claim and get paid for both since they are 2 separate tax numbers? Please if you have any links to confirm the answer I would appreciate it. I can only confirm one facility per month or one physician per month but that is if they have the same tax number.

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    I work for an MD that has a large number of people already signed up for their CCM program (Almost 500 through 4 offices). I have just begun working at the office and am wondering how I will be able to call all of these patients on a monthly basis and still be able to sign up new patients for the program. I am the only one working for the CCM program and need some advise on how to manage making 20 minute phone calls for this amount of people and still signing new patients up. Also, the patients that I do get in touch with on a monthly basis do not want to linger in the phone- “Im fine, I’ll call if I need anything”.Any advise you could give would be wonderful.

    1. blank

      Tiffany, I know you posted this a while ago and I’m sure your company has become more prepared to handle CCM, but I wanted to make sure anyone who read this and had the same questions could get some answers. First and most importantly, if you are going to bill Medicare for 20 minutes, then you can’t only spend 15 minutes on a call and in a chart. There is no way to spend less than 20 minutes/patient to get through all of your patients faster. If a patient is a quick call, says everything is good, doesn’t need anything and takes 3 minutes, you still have to work in their chart the remaining 17 minutes identifying gaps in care/upcoming appointments/needs/etc. and you will have to document that. Honestly, 400 pts for one nurse per month is a LOT and very hard work, but I’m not saying it can’t be done. With 500, you would have to manage every single minute of your day absolutely perfectly and hope nothing technical goes wrong ever. And there is basically no way to complete 500 patients on top of also trying to recruit more signups to the program. There is just not enough time in the day/month. Here’s how it breaks down= If there are 10 hours in a workday, you can try your hardest to complete 3 calls an hour (20 min + 20 min + 20 min = 60 min), somehow not run over a couple minutes on any of the calls, take no breaks, and complete 30 patients. Multiply that x 5 days a week, you’re working 50+ hours and completing 150 patients/week. x 4 weeks in a month=600 minus the 100 patients that took longer than 20 minutes, sometimes 30-40 minutes, and that’s how you could theoretically complete 500/month. But expect to get burned out at that rate, and quickly. I would explain all of this to my boss and explain you need someone’s help before you end up getting so far behind that they lose money. I mean, 500 patients x $42 medicare pays for CCM = $22, 500/month. They can afford to get you some help and give you a raise too, lol.

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    Can CPT code 99490 Chronic Care Management be billed with a modifier 25 when we billed an allergy shot on the same day?

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    Do you know if the medical provider has to actually create the initial CCM document or can this be created by support staff? I can’t seem to get a concrete answer from CMS. The provider will have input within the month of services but the initial document could be created by nursing staff. Thank you

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    Do you have to talk on the phone with the pt for 20 min per month? This is how I take it according to this paragraph.
    CMS has a list of about 22 things the practice needs to do to comply, including engaging with each patient over the phone for 20 minutes each month to coordinate care. It doesn’t have to be one phone call, but could be a five-minute phone call each week, for example.

  9. blank

    Do you have to spend 20 min a month on the phone with the pt? That is the way this paragraph reads:
    CMS has a list of about 22 things the practice needs to do to comply, including engaging with each patient over the phone for 20 minutes each month to coordinate care. It doesn’t have to be one phone call, but could be a five-minute phone call each week, for example.

  10. blank

    Are you still able to bill for the CCM code if you’re participating in an Advanced Payment Model, like CPC+?

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    Many practices (e.g., TPMG) are outsourcing their CCM. We are attempting to serve our patient family by providing this service within the practice (Family Medicine Practice with 5 providers). We have a large Medicare population. We are having problems “organizing” and keeping track of our CCM. It is like we need s “dynamic calendar software” and I have never heard of such.
    e.g. the 1st month we added and performed 10 CCM encounters. The next month we added another ten and performed 20 CCM encounters. The 3rd month we added 10 and performed 30 encounters. You get it. But our problem is that we sometimes add 10 new CCM participants / day. Is their software out there to help organize this stuff? Our practice uses NextGen as our EHR platform (we purchase it from TSI – a software reseller.) Thanks for any help / light that you can shed on this very (and I cannot emphasize how very) important topic. Joe Leming

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    My grandfather has MS and it is really hard for us to care for him sometimes. It does seem like it would be smart for my family to look into getting a professional medical service that does well with managing chronic illness to help him. It seems like that would be best for my family and my grandfather.

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    Thank you so VERY much for putting together this work product and Blog. I and my staff follow and enjoy the Blod relating to Medicare Wellness. This is a welcome addition to our every day existence.

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