How Does CCM Billing Work?

Chronic Care Management billing involves specific codes that healthcare providers use to bill Medicare for the time and resources spent managing patients’ chronic conditions. Whether a patient calls to ask a medical question or you speak with their cardiologist about their care, you can be reimbursed by Medicare for any in-between visit care provided. 

Billable CCM services may include:

• Creation and revision of care plans
• Phone calls
• Medication management, such as prescription refills
• Collaboration with other healthcare providers
• Scheduling appointments
• Chart reviews

One of the significant benefits of CCM billing is that it’s not just physicians who get reimbursed for their services. The care provided by nurses on staff is also billable, meaning you can turn non-revenue-generating staff into revenue-generating staff. 

Eligibility

Patients must meet several criteria according to the Centers for Medicare and Medicaid Services (CMS) in order to be eligible for CCM. The patient must have two or more chronic conditions that are expected to last 12 months or more. These conditions must also put the patient at significant risk of death, acute exacerbation and/or decompensation, or functional decline. 

Billing Code Factors

Different codes are used for reimbursement of different types of CCM. The billing codes used are determined by the following factors:

1. Length of time spent providing care: CCM billing codes cover increments of 20, 30, or 60 minutes of care. However, that doesn’t mean you need to spend the exact increment on one service in order to qualify for reimbursement. For example, providing 5 minutes of care at the beginning of the month, plus 10 minutes in the middle of the month, plus 5 minutes at the end of the month all count toward the initial 20 minutes to qualify for CPT code 99490, even if the care is from different staff members. 
2. Who provided the care: Eligible CCM providers include:
   • Physicians
   • Physician assistants
   • Nurse practitioners
   • Certified nurse midwives
   • Clinical nurse specialists
3. Complexity of care provided: CCM billing codes are divided into standard and complex chronic care management. The amount of time spent providing CCM in a calendar month determines whether the care is considered standard or complex. 

How Often Can Chronic Care Management Be Billed?

CCM can be billed on a monthly basis. Each code covers a different increment of time. Standard CCM codes cover increments of 20 minutes, while complex codes cover 60 minutes of care, plus each additional 30 minutes. You cannot bill both standard and complex codes for a single patient in the same month. 

There is also a limit to how many times you can bill each code for a single patient each month. This is because Medicare determines it is medically unlikely that you would need to bill more than a certain number of times each month for specific services. This limit is referred to as a Medically Unlikely Edit (MUE).

Breaking Down Different Chronic Care Management Billing Codes

1. Standard “Non-Complex” CCM Billing Codes

CPT 99490: 

• Reimburses an average of $61
• Requires a minimum of 20 minutes of non-complex CCM services per calendar month
• Care must be provided by the provider’s clinical staff under the direction of a physician or other qualified healthcare professional
• Can only be billed once per calendar month

CPT 99439:  

• Reimburses an average of $47
• Billed alongside CPT 99490 to cover each additional 20 minutes of non-complex CCM services per calendar month
• Care must be provided by the provider’s clinical staff under the direction of a physician or other qualified healthcare professional
• Can only be billed twice per calendar month

2. Physician-Driven, Non-Complex CCM Billing Codes

CPT 99491

• Reimburses an average of $83
• Requires a minimum of 30 minutes of non-complex CCM services per calendar month
• Care must be provided by the billing physician or other qualified healthcare professional
• Can only be billed once per calendar month per patient

CPT 99437

• Reimburses an average of $58 
• Billed alongside CPT 99437 to cover each additional 30 minutes of non-complex CCM services per calendar month
• Care must be provided by the billing physician or other qualified healthcare professional
• Can only be billed twice per calendar month per patient

3. Complex CCM Billing Codes

CPT 99487 

• Reimburses an average of $131
• Requires a minimum of 60 minutes of complex CCM services per calendar month
• Care must have been directed by a physician or other qualified healthcare professional
• Can only be billed once per calendar month per patient

CPT 99489

• Reimburses an average of $71 
• Billed alongside CPT 99487 to cover each additional 30 minutes of complex CCM services per calendar month
• Care must have been directed by a physician or other qualified healthcare professional
• There is no limit on how many times CPT 99489 can be billed per calendar month per patient

Billing CCM with Remote Patient Monitoring

Combining CCM with Remote Patient Monitoring (RPM) can enhance patient care and streamline the billing process. RPM involves using medical devices to collect and transmit patient data to healthcare providers. Billing for CCM and RPM can be done simultaneously for a single patient, provided the services are distinct and documented separately. On average, 40 minutes of CCM and RPM can generate $147 per patient per calendar month.

Streamline Your CCM Billing with ValueCare Suite

Managing a successful Chronic Care Management program can significantly improve patient satisfaction and boost your revenue. However, it can be difficult to keep track of billable CCM services and whether all the criteria have been met each month. Luckily, ValueCare Suite simplifies this process for you. Our intuitive software optimizes your CMS workflows, transforming in-between visit care into billable time. Book a demo today to see how ValueCare Suite can help you succeed. 

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What Is Remote Patient Monitoring?

Remote Patient Monitoring (RPM) is a Medicare telehealth service. It involves using digital technology to collect health data from patients outside of traditional healthcare settings. This data can include vital signs such as, blood pressure, weight, heart rate, blood sugar levels, and other relevant metrics. Both acute and chronic conditions can be monitored remotely. 

RPM uses various devices to collect data, such as blood glucose meters, blood pressure monitors, weight scales, and pulse oximeters. The data is transmitted electronically and in real time for continuous monitoring and analysis. It allows practitioners to track patient health in between office visits, so they can identify fluctuations and irregularities. They can then provide recommendations and intervene when necessary, improving their patients’ overall health. 

How Does Remote Patient Monitoring Work?

With the patient’s consent, a provider initiates an RPM program to collect specific types of data using one or more monitoring devices. For example, a patient with hypertension would be given a blood pressure monitor so they can measure their blood pressure at regular intervals from the comfort of their home. The device sends the blood pressure readings to the patient’s healthcare team, who can then analyze the data and work together to develop a personalized care plan. 

Five Benefits of Remote Patient Monitoring

1: Enhanced Patient Engagement

RPM empowers patients to take a more active role in managing their health. By receiving real-time feedback and insights, patients become more engaged in their own care. This helps them stick to their treatment plans and make healthier lifestyle choices. 

2: Early Detection of Health Issues

With RPM, practitioners can detect potential health issues at an early stage, even before symptoms manifest. This proactive approach allows for timely interventions, reducing the risk of complications and hospitalizations. 

3: Improved Chronic Disease Management

For patients with chronic conditions such as hypertension, diabetes, or heart disease, ongoing monitoring and care management through RPM is crucial. By continuously tracking key indicators, practitioners can adjust treatment plans as needed to optimize outcomes.  

4: Efficient Use of Resources

Remotely monitoring their patients’ health status allows practitioners to prioritize their time and resources more effectively. Instead of scheduling frequent in-person appointments to track chronic conditions or check on treatment progress, routine check-ins can be conducted virtually, which frees up clinic space.

5: Leveraging Data for Enhanced Patient Care 

RPM generates vast amounts of patient data that can be utilized to inform treatment strategies. By analyzing trends and patterns over time, practitioners can tailor treatments to each patient’s individual needs, leading to more personalized and effective care.

How to Bill for Remote Patient Monitoring

Healthcare providers can bill Medicare and be reimbursed for the qualifying RPM equipment and services they provide. RPM services can also be provided by a practitioner’s clinical staff, and health professionals outside their office, such as pharmacists, as long as they are operating under the general supervision of the billing practitioner. The practitioner compensates the pharmacist for providing RPM, and in turn gets reimbursed by Medicare. 

In order to qualify for reimbursement, all of the following criteria must be met:

1. The RPM service must monitor an acute or chronic condition.
2. The data collection device must meet the FDA definition of a medical device.
3. Data must be collected for at least 16 days of each month.
4. Data must be electronically collected and automatically uploaded to a secure location that the billing practitioner can readily access.

To bill for RPM, you also need to use the right CPT codes: 

• CPT 99453: This code is used for the initial RPM setup and patient education on how to use the equipment.  
• CPT 99454: This code covers supplying the RPM device, as well as collecting and transmitting data. This code can only be used once per patient per 30 days, no matter how many devices are used.
• CPT 99457: This code is used to cover the initial 20 minutes of RPM time requiring interactive patient communication in the calendar month. The RPM service can be performed by the billing physician, clinical staff, or a qualified healthcare professional. 
• CPT 99458: This add-on code is used alongside CPT 99457 for each additional 20 minutes of RPM time in the calendar month. After 99457 has been billed, 99458 can be used up to three times per month to cover 40, 60, or 80 minutes. 

Implement RPM Services for Your Patients with ValueCare Suite

Remote Patient Monitoring (RPM) leads to better patient outcomes and more efficient care. However, keeping track of whether your clinic meets Medicare billing criteria can be challenging. ValueCare Suite offers intuitive software that streamlines your RPM programs with automated workflows to keep staff efficient and on track. Our software includes features like tracking staff time, calculating eligible billing codes, generating patient-centered reports, and providing daily completion alerts. Patient analytics are calculated and easily exported.  Book a demo today to learn more.  

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What Is Chronic Care Management?

Chronic Care Management (CCM) is a Medicare Part B program that allows healthcare providers to bill Medicare for the time and resources spent managing a patient’s chronic condition. It covers all the services a patient’s primary care team provides in between visits, such as developing a care plan, recording patient health information, managing their medications, and coordinating care between providers. 

At least 20 minutes or more of CCM services can be billed per month. However, the patient must have two or more chronic conditions in order for the primary care team to be eligible for reimbursement.  

Why Is CCM Important?

The Chronic Care Management program is designed to improve the quality of life for both patients and practitioners. 

• Patients receive access to important medical resources, more efficient communication with their primary care team, and ongoing support that allows the patients to be more engaged in their own care. 
• Practitioners can be reimbursed for the care provided in-between office visits known as “in-between visit care”. Both the practitioner’s time and their clinical staff time spent on these services are now billable through CCM. These are services already provided but typically not considered billable, such as managing patient medications, reviewing and explaining test results, coordinating care between providers, answering patient questions, and offering health education.
• CCM improves patient-practitioner relationships, which increases patient satisfaction and compliance, and also increases revenue for the healthcare provider.

Key Takeaway: Transform Non-Revenue Tasks into Profit with CCM

In a physician’s office, the main revenue comes from the physician’s work. To increase revenue, you need more physicians and more office visits. One huge benefit of running Chronic Care Management (CCM) is that it turns non-revenue-generating tasks and staff into revenue-generating ones. With CCM services, an employee earning $20-$35 per hour can generate over $120 per hour for the office.

Which Conditions Qualify for Chronic Care Management?

As we mentioned earlier, eligible CCM patients must have two or more chronic conditions. According to the Centers for Medicare and Medicaid Services (CMS), chronic conditions must be expected to last at least one year, or until the patient’s death. Conditions that put the patient “at significant risk of death, acute exacerbation and/or decompensation, or functional decline” also qualify. 

Eligible chronic conditions include, but are not limited to:

• Alzheimer’s disease
• Arthritis
• Asthma
• Autism spectrum disorders
• Cancer
• Cardiovascular disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Depression
• Diabetes
• Glaucoma
• Hypertension
• HIV/AIDS
• Osteoporosis

How Does Billing for CCM Work?

One of the biggest questions practitioners have about Chronic Care Management is how to bill for it. Billing for CCM involves using specific codes to ensure proper reimbursement. Practitioners may submit their claim at the end of the service period (one calendar month), or after completing the minimum required billable time. 

ValueCare Suite software solution takes the guesswork out of structuring your billing codes. Your team documents each care performed, and we categorize the codes and generate a billing report accordingly.

Basic “Non-Complex” CCM Codes

Practitioners can bill for basic CCM using the following codes: (CPT codes 99490 and 99439 are the most common and frequently used in Chronic Care Management (CCM).)

• CPT 99490: A minimum of 20 minutes of non-complex CCM services provided by the provider’s clinical staff under the direction of a physician or other qualified healthcare professional. The maximum billable amount per month is 1 unit.
• CPT 99439: This add-on code is used alongside CPT 99490 for each additional 20 minutes of non-complex CCM services provided by the provider’s clinical staff under the direction of a physician or other qualified healthcare professional. It is billed after the requirements for CPT 99490 have been met. The maximum billable amount per month is 2 units.
• CPT 99491: A minimum of 30 minutes of non-complex CCM services provided personally by the billing physician or other qualified healthcare professional per calendar month. The maximum billable amount per month is 1 unit.
• CPT 99437: This add-on code is used alongside CPT 99491 for each additional 30 minutes of CCM services provided by a physician or other qualified healthcare professional. It is billed after the requirements for CPT 99491 have been met. The maximum billable amount per month is 2 units.

Complex CCM Codes

Billing for complex Chronic Care Management involves the following codes: 

• CPT 99487: This code is used for complex CCM services totaling at least 60 minutes of clinical staff time per calendar month, that were directed by a physician or other qualified healthcare professional.
• CPT 99489: This add-on code is used with CPT 99487 for each additional 30 minutes of complex CCM services provided by clinical staff per calendar month, under the direction of a physician or other qualified healthcare professional. It is billed after the requirements for CPT 99487 have been met. This code covers each additional 30 minutes of complex CCM services provided per calendar month.

While physicians, physician assistants, nurse practitioners, certified nurse midwives, and clinical nurse specialists can all bill for CCM, only one practitioner can receive reimbursement per patient each calendar month. The practitioner can report either non-complex or complex CCM services for each patient per calendar month, but not both. 

As of 2024, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill for CCM using code HCPCS G0511 as well as Transitional Care Management (TCM) services for a single patient in the same calendar month. 

Grow an Effective CCM Program with ValueCare Suite

An effective Chronic Care Management program will lead to better patient satisfaction and higher revenue for their healthcare provider. But keeping track of billable CCM services can be challenging. At ValueCare Suite, we take the guesswork out of implementing successful CCM programs. Our user-friendly software streamlines your CMS workflows and helps you turn activities like phone calls with patients and physician collaboration into billable time. Book a demo today to learn more. 

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Why Pharmacists Are Crucial to Successful Remote Patient Monitoring

RPM software allows providers to track medical data while their patients are at home, instead of waiting for in-person or virtual visits. To be compliant with Medicare’s guidelines this data is automatically transmitted to the provider remotely. The Pharmacists and their clinical staff monitor the vitals from the patients data. offering comprehensive insights into the patient’s health that can be used to inform treatment decisions, manage chronic conditions and prevent unneeded hospitalizations and ER visits.

With this data, providers can detect unusual fluctuations and other health concerns early on, allowing for immediate intervention and better health outcomes. And it can be even more effective when used collaboratively with pharmacists, due to their expertise in medication management, patient education, and real-time monitoring. Here’s how pharmacists can contribute to the success of remote patient monitoring.

1: Medication Management

Pharmacists are well-versed in medications and have a deep understanding of their interactions and side effects, as well as the importance of patient adherence. This expertise is vital in ensuring that patients take their medications as prescribed. Pharmacists can use RPM data to evaluate the patient’s adherence, identify issues as they arise, and recommend medication adjustments to the practitioner to ensure better health outcomes. 

2: Patient Education

Another strength of pharmacists is their ability to communicate complex medical information in an easily digestible way. Since Remote Patient Monitoring only works if the patient consistently submits data, effective patient education is critical. Pharmacists can empower patients with information about the benefits of monitoring their health and the importance of adhering to their prescribed medications. The better a patient understands the importance of RPM, the more likely they are to follow through. 

3: Real-Time Monitoring and Intervention

Pharmacists can also use RPM to help patients manage their conditions in between visits to their Primary Care Provider (PCP). Continuous monitoring helps prevent complications and improves chronic care management by allowing for data collection outside the clinic. Whether it’s tracking blood pressure, glucose levels, or medication adherence, pharmacists can identify potential issues early on and promptly notify the PCP. 

4. Leveraging Existing Patient Relationships

In an RPM partnership between physicians and pharmacies, there’s often an overlap in patient clientele. Pharmacists and their clinical staff can capitalize on these existing relationships, transitioning seamlessly to a proactive care model by managing device data and increasing communication frequency. Patients, already familiar with the pharmacists, appreciate this elevation in care.

Can Pharmacists Bill Medicare for Remote Patient Monitoring?

Practitioners are incentivized to run RPM from Medicare by the potential reimbursements. Medicare pays for the time spent working on RPM  in 20 minute increments with a maximum of 80 minutes a month as well as additional reimbursements for collecting 16 days of devices readings within 30 days. Even though pharmacists play an important role in Remote Patient Monitoring, Medicare does not yet recognize them as billing providers for these services. 

However, providers can contract pharmacists to oversee Remote Patient Monitoring programs under general supervision. This collaboration allows pharmacists to bill the provider as “incident-to” services. The provider will be reimbursed by Medicare for RPM, and can then compensate the pharmacists for services provided. 

Improve Patient Outcomes with Quality RPM Software

With their expertise in medication management, patient education, and real-time monitoring, pharmacists can significantly contribute to the success of managing patients’ chronic conditions. Maximizing the role of pharmacists in Remote Patient Monitoring can improve patient health outcomes, provide a boost in additional revenue to both pharmacy and the physician and decrease exacerbations of issues with patients because of an increased level of proactive care. At ValueCare Suite, we believe in the value these programs provide to patients and see a perfect relationship between physicians and pharmacies who are already working collaboratively to manage RPM.  We provide reliable, easy-to-use RPM systems for pharmacists and practitioners to better manage and scale these programs. Contact us today to book a demonstration. 

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1: RPM Improves Patient Outcomes

A recent randomized controlled trial has shown that RPM helps improve patient outcomes. The monitoring provided by RPM fosters a sense of control, empowering patients to actively participate in their own healthcare management. RPM also allows for early detection of fluctuations, enables timely interventions, and reduces the risk of complications. Plus, any concerns the patient has can be addressed by the patient’s care team over the phone, eliminating the need to wait until the patient’s next in-person appointment to discuss concerns or receive guidance. This level of engagement leads to better health outcomes and enhances the patient’s overall quality of life.  

Remote Patient Monitoring not only makes patients happier and healthier, it also gives them more confidence in managing their conditions. Patients with chronic illnesses like diabetes or hypertension can benefit significantly from RPM. Through the use of RPM devices, patients can monitor their vital signs from the comfort of their own homes. This includes heart rate, blood pressure, glucose levels, weight, and more. 

2: RPM Also Benefits Providers

For practitioners, the advantages of RPM extend far beyond patient outcomes. Utilizing beneficial software like ValueCare Suite for your Remote Patient Monitoring services simplifies the process of tracking and billing Medicare services. Choosing the appropriate software offers numerous advantages for healthcare providers, such as:

• Increased Revenue

Its more efficient managing and billing system helps practitioners see a notable increase in revenue streams. Proactive care also has the potential to reduce hospital readmissions and emergency room visits. 

• Better Treatment Plans

By providing access to continuous and accurate patient data, RPM helps doctors make more informed decisions about treatment plans. 

• Healthier Patient Population

Proactive monitoring enables practitioners to identify and treat potential issues before they escalate, resulting in healthier patients.

• Improved MIPS Scores

Meeting the requirements for Medicare Access and the CHIP Reauthorization Act (MACRA) is more attainable with the comprehensive data provided by RPM. This helps improve your Merit-based Incentive Payment System (MIPS) scores. 

• Increased Patient Satisfaction

Informed and engaged patients are more satisfied with their care, creating a positive feedback loop for both patients and practitioners. 

• Auto-Generated Billing Summaries

These automated summaries simplify your billing procedures and streamline administrative work.

3: RPM Revolutionizes Pharmacy Practices

Pharmacists also stand to gain significantly from Remote Patient Monitoring, because it allows them to collaborate more closely with practitioners. Here are a few ways in which pharmacists can benefit from assisting with RPM services:

• Increased Pharmacy Revenue

Partnering with practitioners in managing patient care plans can open new avenues for pharmacies to generate revenue. While pharmacists cannot bill Medicare for reimbursement, providers may contract pharmacists as clinical staff to assist in delivering Medicare services, such as RPM, and will compensate them for the services rendered. Since these programs fall under the general supervision of the provider, they are billed as “incident-to” services by the provider.

• Better Medication Management

Pharmacists play a crucial role in patient care, including in medication management. RPM gives pharmacists access to a wealth of real-time data that can inform medication adjustments as well as adherence monitoring. With these insights, pharmacists can also inform practitioners of potential issues their patients are having.  

• Improved Communication Between Pharmacists and practitioners

RPM also facilitates communication between pharmacists and practitioners. The shared data ensures that healthcare professionals are all on the same page, fostering a collaborative approach to patient care. This synergy is essential for optimizing medication management and improving patient outcomes. 

Get Reliable Remote Patient Monitoring Software from ValueCare

RPM offers transformative benefits for patients, pharmacists, and practitioners alike. It streamlines preventive care and helps build safer, more accurate, and more affordable healthcare practices for the future. If you’re interested in RPM for your patients, contact ValueCare Suite to book a software demo. We’ll provide you with the systems you need to bill Medicare for remote care. 

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