Chronic Care Management

2020 Medicare Physician Fee Schedule

CCM services are comprehensive care coordination services per calendar month, furnished by a physician or nonphysician practitioner (NPP) managing overall care and their clinical staff, for patients with two or more serious chronic conditions. There are currently two general subsets of codes: One for non-complex chronic care management (starting in 2015, with a new code for 2019) and a set of codes for complex chronic care management (starting in 2017). Tables 21 and 22 list the applicable current codes (abbreviated) and provide a high-level summary of the CCM service elements. We refer readers to the following website for more comprehensive information regarding the CCM codes and the existing requirements for billing them to the PFS, available on our website at https://www.cms.gov/ Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/Care-Management.html.

Table 21: Chronic Care Management Codes (CY 2019)

CPT Code	Summary
99490 (“Non-Complex CCM”)	Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional (QHP), per calendar month
99491 (“Non-Complex CCM”)	Chronic care management services, provided personally by a physician or other QHP, at least 30 minutes of physician or other QHP time, per calendar month
99487 Complex CCM	Complex chronic care management services, first 60 minutes of clinical staff time with moderate or high complexity medical decision-making by the reporting practitioner
99489 Complex CCM	Complex chronic care management services, each additional 30 minutes of clinical staff time with moderate or high complexity medical decision-making by the reporting practitioner

 

Early data show that, in general, CCM services are increasing patient and practitioner satisfaction, saving costs and enabling solo practitioners to remain in independent practice. (https://innovation.cms.gov/Files/reports/ chronic-care-mngmt-finalevalrpt.pdf.)⁸² Utilization has reached approximately 75 percent of the level we initially assumed under the PFS when we began paying for CCM services separately under the PFS. While these are positive results, we believe that CCM services (especially complex CCM services) continue to be underutilized. In addition, we note that, at the February 2019 CPT Editorial Panel meeting, certain specialty associations requested refinements to the existing CCM codes, and consideration of their proposal was postponed. Also, we have heard from some stakeholders suggesting that the time increments for non-complex CCM performed by clinical staff should be changed to recognize finer increments of time, and that certain requirements related to care planning are unclear.

Based on our consideration of this ongoing feedback, we believe some of the refinements requested by specialty associations and other stakeholders may be necessary to improve payment accuracy, reduce unnecessary burden and help ensure that beneficiaries who need CCM services have access to them. Accordingly, we proposed the following changes to the CCM code set for CY 2020.

Table 22: Chronic Care Management Services Summary

CCM Services Summary*

Verbal Consent ·       Informed regarding availability of the service; that only one practitioner can bill per month; the right to stop services effective at the end of any service period; and the cost-sharing applies (if no supplemental insurance). ·       Document that consent was obtained

Initiating Visit for New Patients (separately paid)

Certified Electronic Health Record (EHR) Use ·       Structure Recording of Core Patient Information Using Certified EHR (demographics, problem list, medications, allergies).

24/7 Access (“On-Call” Service)

Designated Care Team Member

Comprehensive Care Management ·       Systematic needs assessment (medical and psychosocial). ·       Ensure receipt of preventive services. ·       Medication reconciliation, management and oversight of self-management.

Comprehensive Electric Care Plan ·       Plan is available timely within and outside the practice (can include facts). ·       Copy of care plan to patient/caregiver (format not prescribed). ·       Establish, implement, revise or monitor the plan.

Management of Care Transitions/Referrals (e.g., discharges, ED visit follow-up, referrals) ·       Create/exchange continuity of care document(s) timely (format not prescribed).

Home-and Community-based Care Coordination ·       Coordinate with any home-and community-based clinical service providers, and document communication with them regarding psychosocial needs and functional deficits.

Enhanced Communication Opportunities ·       Offer asynchronous non-face-to-face methods other than telephone, such as secure email

*All elements that are medically reasonable and necessary must be furnished during the month, but all elements do not necessarily apply every month. Consent only needs to be obtained once, initiating visits are only for new patients or patients not seen within a year prior to initiation of CCM.

1. Non-Complex CCM Services by Clinical Staff (CPT Code 99490, HCPCS Codes GCCC1 and GCCC2)

Currently, the clinical staff CPT code for non-complex CCM, CPT code 99490 (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.) describes 20 or more minutes of clinical staff time spent performing chronic care management activities under the direction of a physician/qualified health care professional (QHP). When we initially adopted this code for payment and, in feedback we have since received, a number of stakeholders suggested that CMS undervalued the PE RVU because we assumed that the minimum time for the code (20 minutes of clinical staff time) would be typical (see, for example, 79 FR 67717 through 67718). In the CY 2017 PFS final rule with comment period, we continued to consider whether the payment amount for CPT code 99490 is appropriate, given the amount of time typically spent furnishing CCM services (81 FR 80243 through 80244). We adopted the complex CCM codes for payment beginning in CY 2017, in part, to pay more appropriately for services furnished to beneficiaries requiring longer service times (see below). Some stakeholders continue to recommend that we should create an add-on code for non-complex CCM performed by clinical staff, such that these services would be defined and valued in 20- minute increments of time with additional payment for each additional 20 minutes of clinical staff time spent performing care management activities.

We agreed that coding changes that identify additional time increments may improve payment accuracy for non- complex CCM. Accordingly, we proposed to adopt two new G codes  with new increments of clinical staff time instead of the existing single CPT code (CPT code 99490). The first G code would have described the initial 20 minutes of clinical staff time, and the second G code would have described each additional 20 minutes thereafter. We intended these would be temporary G codes, to be used for PFS payment instead of CPT code 99490 until the CPT Editorial Panel can consider revisions to the current CPT code set. We said we would consider adopting any CPT code(s) once the CPT Editorial Panel completes its work. We acknowledged that imposing a transitional period during which G codes would be used under the PFS in lieu of the CPT codes is potentially disruptive, and solicited comment on whether the benefit of proceeding with the proposed G codes outweighs the burden of transitioning to their use in the intervening year(s) before a decision by the CPT Editorial Panel.

We proposed that the base code would be HCPCS code GCCC1 (Chronic care management services, initial 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; and comprehensive care plan established, implemented, revised, or monitored. (Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately)). We proposed a work RVU of 0.61 for HCPCS code GCCC1, which we crosswalked from CPT code 99490. We believed these codes would have a similar amount of work since they would have the same intra-service time of 15 minutes.

We proposed an add-on HCPCS code GCCC2 (Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure). (Use GCCC2 in conjunction with GCCC1). (Do not report GCCC1, GCCC2 in the same calendar month as GCCC3, GCCC4, 99491)). We proposed a work RVU of 0.54 for HCPCS code GCCC2 based on a crosswalk to CPT code 11107 (Incisional biopsy of  skin (e.g., wedge) (including  simple closure, when performed); each separate/additional   lesion    (List separately  in  addition  to  code  for primary procedure)), which has a work RVU of 0.54, which we believed would accurately reflect the work associated with each additional 20 minutes of CCM services. Both codes would have the same intraservice time of 15 minutes. We noted that the nature of the PFS relative value system is such that all services are appropriately subject to comparisons to one another. Although codes that describe clinically similar services are sometimes stronger comparator codes, codes need not share the same site of service, patient population, or utilization level to serve as an appropriate crosswalk. In this case, we believed CPT code 11107 shared a similar work intensity to proposed HCPCS code GCCC2.

Furthermore, although HCPCS codes GCCC1 and GCCC2 would share the same intraservice time, add-on codes may have lower intensity than the base codes because they describe the continuation of an already initiated service.

We solicited public comment on whether we should limit the number of times HCPCS code GCCC2 could be reported in a given service period for a given beneficiary. It was not clear how often more than 40 minutes of clinical staff time is currently spent or is medically necessary. In addition, once 60 minutes of clinical staff time is spent, many or most patients might also require complex medical decision- making, and such patients would already be described under existing coding for complex CCM. We believed a limit (such as allowing the add-on code to be reported only once per service period per beneficiary) may be appropriate in order to maintain distinctions between complex and non- complex CCM, as well as appropriately limit beneficiary cost sharing and program spending to medically necessary services. We noted that complex CCM already describes (in part) 60 or more minutes of clinical staff time in a service period. We solicited comment on whether and how often beneficiaries who do not require complex CCM (for example, do not require the complex medical decision making that is part of complex CCM) would need 60 or more minutes of non- complex CCM clinical staff time and thereby warrant more than one use of HCPCS code GCCC2 within a service period.

Comment: Several commenters supported the proposed add-on HCPCS code GCCC2, and recommended that there be a limit on its use (frequency) to keep non-complex CCM distinct from complex CCM. These commenters stated that patients requiring multiple uses of the add-on service likely require the moderate to high medical decision making of complex CCM. Other commenters stated that, while they have patients who do not require the complex medical decision making that is part of complex CCM, care management for these patients is time-consuming and would require 60 or more minutes of non-complex CCM clinical staff time within a service period. These commenters suggested that limiting the frequency of reporting HCPCS code GCCC2 to twice during a service period allows for accurate payments, while preventing inappropriate use of the code. The Medicare Payment Advisory Commission (MedPAC) expressed support for the proposed add-on code for non-complex CCM because it would better reflect the resources involved in furnishing care management services and increase payment accuracy for CCM. Other commenters stated that G codes would help to facilitate earlier implementation and would ease transition to any updates made to CPT codes.

However, a number of commenters were not supportive of the introduction of temporary G codes within the CCM code set, believing it would produce administrative burden and cause confusion. These commenters stated that in September 2019 the CPT Editorial Panel was considering an application for similar changes to refine the code set. These commenters urged us to work with the CPT Editorial Panel regarding changes to the CCM code set and its revaluation. A few commenters suggested that CMS could achieve its burden reduction goals by continuing to recognize CPT codes 99490, 99487, and 99489 and also provide CMS-specific guidance for those codes for purposes of billing Medicare.

Response: We are not finalizing our proposal to create HCPCS codes GCCC1 (or GCCC3 or GCCC4, see below) in consideration of commenters’ concerns that the introduction of temporary G codes replacing most of the CCM code set would create administrative burden, especially in light of the CPT Editorial Panel’s currently ongoing work in this area. However we are finalizing GCCC2 (the add-on for non-complex CCM clinical staff time), henceforth referred to as G2058, because this code addresses what we believe is an important gap in the current code set that should be addressed more immediately, and that finalizing only this single G code rather than the full range of proposed G codes will allow payment for these services while creating significantly less administrative burden. Practitioners who choose to use G2058 can report the initial 20 minutes of non-complex CCM under CPT code 99490 and receive increased payment for their work under G2058. We are sympathetic to commenters’ concerns that the introduction of temporary replacement G codes across the CCM code set may introduce substantial confusion or administrative burden, but we believe a single new G code to pay more for additional 20-minute increments of non- complex CCM clinical staff time is important to pursue now. We are finalizing the work RVU for G2058 as proposed.

We agree with commenters that there should be a frequency limit on the reporting of HCPCS code G2058 to maintain the distinction between complex and non-complex CCM and, in response to comments, we are finalizing that HCPCS code G2058 will be reportable a maximum of two times within a given service period for a given beneficiary. We believe the availability of this G code will further our policy goals to improve payment accuracy for care management services and allow practitioners and their teams to spend more time with their patients.

Comment: A few commenters suggested that CMS should revalue the work RVUs for the CCM codes given that we proposed to increase the work RVUs for TCM, and CCM was originally valued based upon the RVUs for TCM.

Response: We appreciate these suggestions but, given the ongoing work of the CPT Editorial Panel regarding these codes, we will consider potential revaluation of this code set in the context of any future changes or recommendations that may be made by the CPT Editorial Panel or the RUC.

1. Complex CCM Services (CPT Codes 99487 and 99489, and HCPCS Codes GCCC3 and GCCC4)

There are two CPT codes for complex CCM:

• CPT code 99487 (Complex chronic care management services, 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; establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. (Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not reported separately); and
• CPT code 99489 (each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

Complex CCM describes care management for patients who require not only more clinical staff time, but also complex medical decision-making and establishment or substantial revision of the care plan. Specifically, the CPT codes for complex CCM include in the code descriptors a requirement for establishment or substantial revision of the comprehensive care plan. The code descriptors for complex CCM also include moderate to high complexity medical decision-making (moderate to high complexity medical decision- making is an explicit part of the services).

We proposed to adopt two new G codes that would be used for billing under the PFS instead of CPT codes 99487 and 99489, and that would not include the service component of substantial care plan revision. We believed it is not necessary to explicitly include substantial care plan revision because patients requiring moderate to high complexity medical decision making implicitly need and receive substantial care plan revision. The service component of substantial care plan revision is potentially duplicative with the medical decision making service component and, therefore, we believed it is unnecessary as a means of distinguishing eligible patients. Instead of CPT code 99487, we proposed to adopt HCPCS code GCCC3 (Complex chronic care management services, 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; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. (Complex chronic care management services of less than  60  minutes duration, in a calendar month, are not reported separately)). We proposed a work RVU of 1.00 for HCPCS code GCCC3, which is a crosswalk to CPT code 99487.

Instead of CPT code 99489, we proposed to adopt HCPCS code GCCC4 (each additional 30 minutes of clinical staff time directed by a  physician  or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure). (Report GCCC4 in conjunction with GCCC3). (Do not report GCCC4 for care management services of less than 30 minutes additional to the first 60 minutes of complex chronic care management services during a calendar month)). We proposed a work RVU of 0.50 for HCPCS code GCCC4, which is a crosswalk to CPT code 99489.

We intended these would be temporary G codes to remain in place until the CPT Editorial Panel can consider revising the current code descriptors for complex CCM services. We stated that we would consider adopting any new or revised complex CCM CPT code(s) once the CPT Editorial Panel completes its work. We acknowledged that imposing a transitional period during which G codes would be used under the PFS in lieu of the CPT codes is potentially disruptive. We solicited comment on whether the benefit of proceeding with the proposed G codes outweighs the burden of transitioning to their use in the intervening year(s) before a decision by the CPT Editorial Panel.

Comment: While expressing general support for the proposed changes to these codes to remove the element of substantial care plan revision, several commenters expressed concerns that the temporary introduction of G codes would produce administrative burden and cause confusion. These commenters stated that in September 2019 the CPT Editorial Panel was considering an application for similar changes to refine the code set and clarify care planning.

These commenters urged us to work with the CPT Editorial Panel regarding changes to the CCM code set and its revaluation. However, other commenters stated that G codes would help to facilitate earlier implementation and would ease transition to any updates made to CPT codes. A few commenters suggested that CMS could achieve its burden reduction goals by continuing to recognize CPT codes 99490, 99487, and 99489 and also provide CMS-specific guidance for those codes for purposes of billing Medicare.

Response: We are not finalizing our proposal to create HCPCS codes GCCC3 and GCCC4 in light of concerns raised by commenters, especially in light of the CPT Editorial Panel’s currently ongoing work in this area and the concerns expressed by those that we expect would likely provide these services.

Instead, given the support for our proposed care planning changes, for CY 2020 we will continue to recognize CPT codes 99487 and 99489, but with a different care planning element for purposes of billing Medicare. Beginning in CY 2020, for PFS billing purposes for CPT codes 99487 and 99489, we will interpret the code descriptor ‘‘establishment or substantial revision of a comprehensive care plan’’ to mean that a comprehensive care plan is established, implemented, revised, or monitored. This will allow for consistency in the care planning service element of complex CCM and non- complex CCM services provided by clinical staff. While we usually create G codes with alternative code descriptors when our payment policy varies from what is included in a CPT code descriptor(s), the change we proposed for the complex CCM care plan code descriptor is a relatively minor modification to the CPT code descriptor that we believe can be accomplished without the use of G codes. We look forward to reviewing any refinements or other recommendations for these services that may come from the CPT Editorial Panel and the RUC, and will consider such recommendations through our rulemaking process.

1. Typical Care Plan

In 2013, in working with the physician community to develop and propose the CCM codes for PFS payment, the medical community recommended and CMS agreed that adequate care planning is integral to managing patients with multiple chronic conditions. We stated our belief that furnishing care management to beneficiaries with multiple chronic conditions requires complex and multidisciplinary care modalities that involve, among other things, regular physician development and/or revision of care plans and integration of new information into the care plan (78 FR 43337). In the CY 2014 PFS final rule with comment period (78 FR 74416 through 74418), consistent with recommendations CMS received in 2013 from the AMA’s Complex Chronic Care Coordination Workgroup, we finalized a CCM scope of service element for a patient-centered plan of care with the following characteristics: It is a comprehensive plan of care for all health problems and typically includes, but is not limited to, the following elements: Problem list; expected outcome and prognosis; measurable treatment goals; cognitive and functional assessment; symptom management; planned interventions; medical management; environmental evaluation; caregiver assessment; community/social services ordered; how the services of agencies and specialists unconnected to the practice will be directed/coordinated; identify the individuals responsible for each intervention, requirements for periodic review; and when applicable, revisions of the care plan.

The CPT Editorial Panel also incorporated and adopted this language in the prefatory language for Care Management Services codes (page 49 of the 2019 CPT Codebook) including CCM services.

As we continue to consider the need for potential refinements to the CCM code set, we have heard that there is still some confusion in the medical community regarding what a care plan typically includes. We re-reviewed this language for CCM, and we believe there may be aspects of the typical care plan language we adopted for CCM that are redundant or potentially unduly burdensome. In our CY 2020 PFS proposed rule, we noted that because these are ‘‘typical’’ care plan elements, these elements do not comprise a set of strict requirements that must be included in a care plan for purposes of billing for CCM services; the elements are intended to reflect those that are typically, but perhaps not always, included in a care plan as medically appropriate for a particular beneficiary. Nevertheless, we proposed to eliminate the phrase ‘‘community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identify the individuals responsible for each intervention’’ and insert the phrase ‘‘interaction and coordination with outside resources and practitioners and providers.’’ We believed simpler language could describe the important work of interacting and coordinating with resources external to the practice. While it is preferable, when feasible, to identify who is responsible for interventions, it may be difficult to maintain an up-to-date listing of responsible individuals especially when they are outside of the practice, for example, when there is staff turnover or assignment changes.

We proposed new language to read: The comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:

• Problem list.
• Expected outcome and prognosis.
• Measurable treatment goals.
• Cognitive and functional assessment.
• Symptom management.
• Planned interventions.
• Medical management.
• Environmental evaluation.
• Caregiver assessment.
• Interaction and coordination with outside resources and practitioners and providers.
• Requirements for periodic review.
• When applicable, revision of the care plan.

We welcomed feedback on our proposal, including language that would best guide practitioners as they decide what to include in their comprehensive care plan for CCM recipients.

Comment: Commenters largely supported CMS’ proposed definition of the typical care plan, and stated that it was simpler than the current definition and also comprehensive.

Response: We thank the commenters for their support and are finalizing our proposed changes to the typical care plan for all CCM. We are eliminating the phrase ‘‘community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identify the individuals responsible for each intervention’’ and inserting the phrase ‘‘interaction and coordination with outside resources and practitioners and providers.’’ The new language will read: ‘‘The comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:

• Problem list.
• Expected outcome and prognosis.
• Measurable treatment goals.
• Cognitive and functional assessment.
• Symptom management
• Planned interventions.
• Medical management.
• Environmental evaluation
• Caregiver assessment
• Interaction and coordination with outside resources and practitioners and providers.
• Requirements for periodic review.
• When applicable, revision of the care plan.’’

We anticipate that this change will reduce burden and simplify the important work of interacting and coordinating with resources external to the practice.