Clinical Context
A typical patient is a 74-year-old Medicare beneficiary with multiple chronic conditions such as congestive heart failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. The patient receives primary care in an outpatient clinic or via a home health program. The provider delegates care coordination tasks to clinical staff (nurse, licensed practical nurse, medical assistant) who spend time each calendar month under the provider’s direction performing activities such as medication reconciliation, monitoring adherence, arranging specialty referrals, communicating with home health or social work, and documenting care plan updates in the electronic health record. The team documents the start and stop times of clinical staff work, ensuring at least 20 minutes of provider-directed staff time in the calendar month to bill 99490. Typical sites of service include outpatient office visits, patient homes, and home health settings where non-face-to-face care management and coordination occur. The workflow includes an initial assessment of chronic condition burden, creation or update of a comprehensive care plan, monthly follow-up contacts (phone, telehealth platform, or chart review) by clinical staff, and escalation to the provider when clinical changes or medication adjustments are needed.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
99487 | Complex chronic care management services, with substantial care coordination, first hour of clinical staff time directed by a physician or other qualified health care professional, per calendar month | Use for patients requiring more intensive, complex chronic care management beyond the baseline monthly 20 minutes covered by 99490. |
| 99489 | Complex chronic care management services, each additional 30 minutes | Use to add time-based complexity beyond the initial hour when clinically indicated after 99487.
| 99491 | Chronic care management services furnished personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time per calendar month | Use when the provider personally delivers at least 30 minutes of care management time rather than delegating to clinical staff.
| 98960 | Education and training for patient self-management by a qualified nonphysician health care professional, face-to-face; initial 30 minutes | Use when structured self-management education is provided in-person and complements monthly care coordination.
| 99091 | Collection and interpretation of physiologic data digitally stored and/or transmitted by the patient to the physician or other qualified health care professional, requiring a minimum of 30 minutes of time | Use when remote patient monitoring data are reviewed as part of chronic care management and documented within the monthly service.