Physicians who work with older adults recognize that chronic conditions like high blood pressure and diabetes can wreak havoc on patients’ long-term health. Without proper management of chronic conditions – often difficult as patients are usually left to their own devices between clinic visits – patients are at higher risk of unnecessary hospital admissions, emergency room visits and even death.
A key priority for providers, then, should be working with chronic care patients to prevent chronic conditions from worsening. The Centers for Medicare & Medicaid Services (CMS) agrees, and so has established reimbursement codes for care services designed to help these patients manage chronic illnesses, including remote patient monitoring (RPM) and Chronic Care Management (CCM) services.
Here, we break down the basics of CCM and RPM, the benefits for patients, how they can increase medical practice revenue and the key reimbursement codes you need to know if you want to deploy these services with your chronic care patients.
What is chronic care management (CCM)?
Chronic care management, often abbreviated as CCM, is a form of supplemental care designed to help patients with chronic health conditions better maintain their health long term and avoid negative health outcomes. Chronic conditions are defined by CMS as illnesses expected to last at least 12 months (or until the death of the patient) that put patients at significant risk of death, acute exacerbation/decompensation or functional decline.
CCM typically covers patients with two or more chronic conditions who have a continuous relationship with their care team and sees providers offering support via care plan formation, remote communication or coaching (typically via phone), care coordination between providers, prescription management and more.
These services not only help patients with chronic conditions get support with their ongoing health issues, but can also increase their access to healthcare resources, help them build deeper relationships with their care team and encourage greater engagement with their health via goal-setting, tracking and progress reports. Physicians also often benefit from improved care coordination and higher patient satisfaction.
The key perk for many independent physicians, however, is CMS reimbursement. Since 2015, CMS has been offering reimbursement for providers who offer chronic care management to qualifying patients in order incentivize those who provide this much-needed care outside of typical clinic visits. Provisioned under Medicare part B, CCM services are eligible for reimbursement with original Medicare, with different services tied to different billing codes and aspects of chronic care.
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Chronic care management CPT codes
Reimbursement codes for CCM are divided into non-complex chronic care management and complex chronic care management, with the latter accounting for more care team service time, greater involvement of the billing practitioner and more extensive care planning.
Some of the codes require services to be provided by physicians or non-physician practitioners, while others include services offered by clinical staff under the supervision and direction of a physician or non-physician practitioner. This means that even if an independent physician does not have the capacity to handle all aspects of CCM services themselves, they may still be able to bill for services offered by eligible staff as part of their patient care plan.
Depending on patient eligibility and services offered, providers will commonly bill CMS for one or more of the following CPT codes.
|CPT Code||Services covered||Complex vs. non-complex||Reimbursement rate*|
|99490||20 minutes of care by a provider or qualified healthcare professional||Non-complex||$62|
|99491||30 minutes of care by a provider or qualified healthcare professional||Non-complex||$74|
|99439||Additional 20-minute block of CCM services||Non-complex||$47|
|99487||60 minutes of care by a provider or qualified healthcare professional||Complex||$130|
|99489||Additional 30-minute block of CCM services||Complex||$69|
CPT 99490 is the most common non-complex chronic care management billing code and covers up to 20 minutes of care by a provider or qualified healthcare professional. To qualify for reimbursement, providers must document 20 minutes of non-face-to-face care per calendar month for each enrolled CCM patient. To be eligible, patients must have two or more chronic conditions (expected to last at least 12 months or until death).”Care” here is used in a broad sense can include a wide variety of activities that support the management of chronic conditions, including, but not limited to:
- Establishing, monitoring, revising, or implementing a chronic care plan
- Refilling prescriptions
- Arranging appointments and coordinating care
- Arranging transportation
- Updating medical records
These services must be documented in a comprehensive care plan and can be billed once per calendar month on an ongoing basis at a rate of $62 for each eligible patient who receives this care. This is a 51% increase over the reimbursement rate offered pre-2022, prior to the most recent Medicare Physician Fee Schedule Final Rule. This code is billable monthly.
Like CPT 99490, CPT 99491 covers patients with two or more chronic conditions and carries all of the same basic reimbursement requirements. The key difference is the amount of care given to each patient.
Where CPT 99490 covers up to 20 minutes of care by a provider or qualified healthcare professional, CPT 99491 covers up to 30 minutes of care. This code cannot be billed with CPT 99490 for the same patient in the same month, so may be a better choice for higher-risk patients. CPT 99491 can be billed at an average rate of $74 for each eligible patient who receives this care.
This CPT code is a supplement to CPT 99490 or 99491 and carries all of the same basic eligibility requirements. CPT 99439 covers up to two additional 20-minute blocks of CCM services per patient per calendar month and can be billed at a rate of $47 for each eligible patient who receives this care. This code is billable as needed, up to two times per month.
What is remote patient monitoring (RPM)?
Remote patient monitoring, or RPM for short, is often used as a supplement to CCM and sees providers collecting physiologic data from health monitoring devices – such as blood glucose monitors, blood pressure monitors, scales and pulse oximeters – in order to track and manage conditions remotely.
Providers give qualifying patients devices to use at home and data is transmitted electronically. To qualify for reimbursement, RPM data must be collected in this way and cannot be self-reported by the patient or collected with their personal devices.
Remote patient monitoring CPT codes
In 2018, CMS introduced CPT codes to reimburse providers for delivering RPM services to patients. The RPM reimbursement codes are similar to the Chronic Care Management (CCM) codes, but add device data collection and review to the requirements.
Here is a breakdown of the RPM CPT codes and reimbursements currently available:
|CPT Code||Services covered||Reimbursement rate*|
|99453||Initial device setup||$21|
|99454||Ongoing vitals monitoring via devices||$49|
|99457||20 minutes of monitoring and care management (includes interactive communication with patient)||$49|
|99458||Additional 20 minutes of monitoring and care management services||$40|
CPT 99453: Initiation of device monitoring and setup
This code covers time spent setting up a new device for a patient and is reimbursed at an average rate of $21 per instance. This requires a prescription, patient consent, and that the device is able to automatically transmit data to the selected provider.
Note that this code can only be reimbursed once per patient per 30-day period, even if the patient is using multiple RPM devices. The reimbursement rate for this code saw a modest increase of 13% in 2022.
CPT 99454: Physiologic monitoring with devices
CPT code 99454 covers remote monitoring of physiological data with a device, and a reimbursement of $49 can be filed once every 30 days. To use this code, data must be transmitted to the provider or an alert must be sent on at least 16 days out of each 30-day period. This was one of the more dramatic rate drops we saw to RPM codes in 2022, dropping 14%. Such rate drops for RPM may encourage more providers to bundle CCM services with RPM services instead of offering the latter in isolation.
CPT 99457: Clinical follow up on physiologic monitoring
CPT 99457 offers reimbursement of $49 (up 4% versus 2021) each calendar month for a minimum of 20 minutes of live communication with the patient by physicians, qualified health care professionals or clinical staff. This time is typically spent discussing physiologic data and progress with patients.
CPT 99458: Two extra 20-minute blocks of non-face-to-face interaction
This CPT codes covers an additional 20 minutes of remote physiologic monitoring treatment management services, and clinical time in a calendar month requiring interactive communication with the a patient or caregiver during the month. This code saw a drop in reimbursement rate, down 6% to $55 in 2022.