Neurology & Pain Management Coding Alert

Do you know the differences between standard and complex chronic care management?

Chronic care management (CCM) is vital for some patients at your practice: It closes gaps between office visits for Medicare beneficiaries who live with multiple chronic conditions; it provides support that reduces hospitalizations; and, most importantly, it improves outcomes.

To ensure that a patient’s documentation meets payers’ strict requirements, coders need to correctly identify eligible patients and apply the right CPT^® codes.

Do you know how to determine whether documentation indicates that CCM is medically necessary, or if the CCM is standard or complex? Read on to refresh your skills for coding CCM.

Understand Eligible Chronic Conditions

Coders can apply CCM codes for patients who have two or more active chronic conditions that pose a significant morbidity or mortality risk, and these conditions are expected to last at least 12 months.

Keep in mind that historical diagnoses do not count toward a patient’s eligibility for CCM. To qualify, a patient must have two or more active chronic conditions that put them at risk for functional decline, acute exacerbation, or death.

Some common qualifying conditions include, but are not limited to:

• E11.- (Type 2 diabetes mellitus)
• E78.- (Disorders of lipoprotein metabolism and other lipidemias)
• F33.- (Major depressive disorder, recurrent)
• F41.1 (Generalized anxiety disorder)
• G30.- (Alzheimer’s disease)
• G35.- (Multiple sclerosis)
• I10.- (Essential (primary) hypertension)
• I50.- (Heart failure)
• J44.- (Other chronic obstructive pulmonary disease)
• M15.- (Polyosteoarthritis) toM19.- (Other and unspecified osteoarthritis)

Recognize Evidence for Chronic Care Management

There are six main criteria that coders need to know in order to prove that CCM is medically necessary:

1. The patient must have two or more chronic conditions that meet the duration (at least 12 months, or until death) and risk (functional decline, acute exacerbation, or death) criteria.

2. These chronic conditions must require ongoing clinical management. Look for phrases like “requires ongoing medication adjustments and monitoring across multiple specialties” or “conditions place the patient at increased risk of acute decompensation.” These are flags that indicate a patient may qualify for CCM.

3. A comprehensive care plan should be shared with the patient. It should address physical, mental, cognitive, psychosocial, functional, and environmental factors that affect the patient’s chronic condition or their care.

4. The patient must provide verbal or written consent to participate in CCM.

5. CCM must include non-face-to-face services, such as coordination with specialists, medication management, education, or monitoring.

6. The time threshold for standard CCM is 20 minutes per calendar month; the threshold for complex CCM is 60 minutes per calendar month.

Recognize Differences Between Standard and Complex CCM

Standard CCM applies when patients need routine coordination of stable or moderately controlled chronic conditions. It typically involves low-complexity medical decision making (MDM) and updates to care plans rather than extensive revisions.

Coders should use 99490 (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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month) and +99439 (… 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)) when standard CCM is performed by clinical staff and directed by a physician or qualified healthcare professional.

If the physician or qualified healthcare professional personally performs the service, report 99491 (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 that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month.) and +99437 (… each additional 30 minutes by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)), as appropriate.

Complex CCM is appropriate for patients with unstable, high-risk, or highly symptomatic conditions that require intensive coordination and moderate-to high-complexity MDM. This may include frequent medication titration, coordination with multiple specialists, hospitalizations, and close monitoring. Coders should use 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 that 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; first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.) and +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)) for complex CCM time with moderate or high MDM. To support correct billing, coders must confirm that the time and complexity of the medical decisions are documented in the patient’s record.

Michelle Falci, BA, M Falci Communications LLC