3 Challenges of Reporting Care Management Services in 2023

by | Published on Mar 22, 2023 | Medical Billing

Billing Care Management Services
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Care management refers healthcare activities performed with the aim to promote coordinated care for people who require ongoing medical attention. In this approach, health care is individualized to meet each patient’s specific needs. Care management greatly benefits patients with chronic conditions, such as diabetes, heart disease, or cancer, as well as patients with acute or complex medical needs. Medical billing outsourcing companies are well-positioned to help physicians report their services correctly for optimal reimbursement. Having such support is crucial as according to recent reports, providing care management (CCM) and principal care management (PCM) services and billing them comes with specific challenges.

Goals and Components of Care Management

The main goals of care management are:

  • To provide comprehensive, effective, and efficient care that enhances health outcomes and patient satisfaction
  • To prevent chronic disease, stabilize current chronic conditions, and prevent escalation to higher-risk categories
  • To reduce healthcare costs by preventing unnecessary hospitalizations, emergency department visits, and other medical interventions

The American Academy of Family Physicians (AAFP) lists the key components of care management as:

  • Patient education
  • Medication management and adherence support
  • Risk stratification
  • Population management
  • Coordination of care transitions
  • Care planning

Providing care management services is challenging. The AAFP notes that to succeed with care management, family practice physicians practice need to assign a health risk status to a patient, and then get care team members to collaborate with each patient to plan, develop, and implement an individualized care plan. High risk patients will need an increased level of support.

The costs of providing individualized care for patients with chronic or acute conditions depend on factors such as practice characteristics, patient populations, payer mix, and the payment model providers participate in. Physicians need to ensure that they have proper billing practices in place that will help balance those costs.

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Challenges of Billing Care Management Services

Billing care management services involves certain challenges:

  • Lack of consistent care for patients with chronic diseases: First, not enough patients actually participate in care management with a primary care physician (www.medicaleconomics.com). Though the Medicare population and the number of patients with chronic diseases are growing, there are fewer primary care providers available to take care of them.
  • Challenges of remote patient monitoring: Remote patient monitoring (RPM) has emerged as a convenient and effective way to provide care, and its use increased during the COVID-19 pandemic. Today, with its data-driven approach, RPM is recognized as an effective way to proactively manage chronic disease like diabetes, heart failure, COPD, and hypertension. However, there are challenges involved: implementing the system and training staff, resolving patient difficulties of using the technology, and identifying patients for remote care and in-person care. All of these issues increase the time needed for caring for each patient, which can increase wait times and other challenges if not managed properly.
  • Coding and documentation: While they have managed chronic care for years, family physicians face many challenges when it comes to optimizing payment for care management. Chronic care management (CCM) is a time-based service with its own documentation and billing requirements. Principal care management (PCM) services are services for patients with a single high-risk disease or complex condition. Attention to detail coding and documentation requirements

Given these challenges, it’s important that providers stay current on Medicare coding and documentation rules for CCM and PCM services to get paid for the time spent on managing care plans.

Ensure Accurate Coding for CCM and PCM

Both CCM and PCM codes are similar in that the work involves the establishment, implementation, revision and monitoring of a care plan for a patient. The difference is that PCM focuses on a single condition

PCM services: Medicare accepts the following 4 PCM codes which are based on time and who is providing the service:

99424 – Principal care management services, for a single high-risk disease… first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month

+99425 – each additional 30 minutes (list separately in addition to code for primary procedure)

99426 – Principal care management services, for a single high-risk disease… first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month

+99427 – each additional 30 minutes (list separately in addition to the code for primary procedure)

Key points to note:

  • These codes can only be billed once per calendar month; both the principal and add-on codes are not billable at all if less than 30 minutes are documented.
  • PCM services and other care management services cannot be billed in the same calendar month
  • 99426 and +99427 require ‘direct’ physician or QHCP supervision (the physician has to be immediately available though not necessarily in the same room)
  • Per CPT, the following are required to bill these PCM codes:
    • One complex chronic condition expected to last at least three months, which puts the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death
    • Condition requires development, monitoring, or revision of disease-specific care plan
    • Condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities
    • Ongoing communication and care coordination between relevant practitioners providing care
    • The first 30 minutes of care are provided personally by a physician or other QHCP, per calendar month

CCM services: CCM involves monitoring two or more chronic conditions. The relevant CPT codes for CCM services are:

99487 – Complex CCM, a 60-minute timed service provided by clinical staff to substantially revise or establish comprehensive care plan that involves moderate- to high-complexity medical decision making.

99489 – Each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualified health care professional (report in conjunction with CPT code 99487; cannot be billed with CPT code 99490).

99490 – Non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability

99439 – Each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified health care professional (billed in conjunction with code 99490)

99491 – CCM services provided personally by a physician or other QHCP for at least 30 minutes.

99437 – Subsequent 30 minutes of care personally provided by a physician or QHCP, per calendar month (list separately in addition to code for primary procedure)

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Providing CCM and PCM services are can be challenging. As physicians strive to provide quality care for patients with chronic conditions, outsourced billing services are a practical option to stay on top of PCM and CCM billing and coding and obtain timely and accurate Medicare reimbursement.


Loralee Kapp

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.

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