Summary & Overview

HCPCS G2064: Comprehensive Care Management for One High-Risk Disease

HCPCS Level II code G2064 denotes comprehensive care management for a single high-risk chronic disease, requiring at least 30 minutes of clinician time per calendar month focused on a disease-specific care plan. The code captures services for patients with a complex chronic condition lasting at least three months that places them at risk of hospitalization, has recently caused hospitalization, requires care-plan development or revision, or demands frequent medication adjustments or complex management due to comorbidities. Nationally, this code is relevant to care coordination initiatives, chronic disease management programs, and payer efforts to reduce avoidable admissions.

Key payers covered include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical intent, likely sites of service, and the types of programs and workflows that use this code. The publication summarizes benchmarking and policy considerations, outlines typical clinical context where G2064 applies, and highlights payer coverage patterns and administrative considerations where available. Data not available in the input will be noted as such in detailed sections.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG2064HCPCS Level IIcare managementchronic disease managementcare coordinationoutpatientphysician servicestelehealth-capablecare plan

Billing Code Overview

HCPCS Level II code G2064 describes comprehensive care management services for a single high-risk disease. The service requires at least 30 minutes of physician or other qualified health care professional time per calendar month and applies when a single complex chronic condition has lasted at least 3 months and is the focus of a disease-specific care plan. The condition must be of sufficient severity to place the patient at risk of hospitalization or have been the cause of a recent hospitalization, require development or revision of a disease-specific care plan, require frequent adjustments in medication regimen, and/or be unusually complex to manage because of comorbidities.

Service Type: Comprehensive care management for one high-risk chronic disease, involving coordinated, ongoing professional time and care planning.

Typical Site of Service: Outpatient settings or ambulatory care where physicians or other qualified health care professionals provide monthly care management time; services may also be delivered via telehealth or in clinic-based chronic care management programs when consistent with payer policies.

Clinical & Coding Specifications

Clinical Context

A 72-year-old patient with a single complex chronic condition such as advanced congestive heart failure (CHF) has been enrolled in a comprehensive care management program using billing code G2064. The patient has had at least one hospitalization in the prior 12 months for decompensated heart failure and requires frequent medication adjustments (diuretics, ACE inhibitors) and a disease-specific care plan with close monitoring. Each calendar month a physician or other qualified health care professional spends at least 30 minutes on care coordination activities focused on the CHF: medication reconciliation and adjustment, coordination with cardiology and home health, arranging durable medical equipment, patient education on weight and symptom monitoring, and updates to the disease-specific care plan.

Clinical workflow: After hospital discharge or identification as high-risk, the primary clinician documents the eligible chronic condition and develops a disease-specific care plan. Monthly care management encounters are scheduled (telephonic or face-to-face) and documented, with time tracked to confirm at least 30 minutes of clinician time. Interventions documented include medication regimen changes, referrals to specialists, care-plan revisions, and documentation of risk for hospitalization. Communication with other care team members (nurse care manager, pharmacist, home health) and patient/caregiver education are recorded. Billing uses G2064 for the monthly comprehensive care management service when all code criteria are met.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when services required substantially greater effort than usual for monthly comprehensive care management (documentation must justify).
`23`	Unusual anesthesia	Rare for this service; not typically used but available if anesthesia was unexpectedly required during a related procedure.
`52`	Reduced services	Use when the service delivered was partially reduced or not completed but still billed.
`53`	Discontinued procedure	Use if the monthly care-management encounter was started but discontinued due to patient condition or other valid reason.
`54`	Surgical care only	Not typically applicable; used when another provider bills only the surgical portion of a related procedure.
`55`	Postoperative management only	Not typically applicable; use if billing relates solely to postoperative care distinct from the comprehensive care plan.
`56`	Preoperative management only	Uncommon; use if service represents only preoperative care separate from chronic disease management.
`62`	Two surgeons	Not typically applicable to this nonprocedural service; use if two practitioners of the same specialty are required for a related procedure.
`78`	Unplanned return to OR	Not applicable to routine `G2064` use; included for completeness when related procedures occur.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist services furnished under a physician's supervision in ambulatory surgical setting	Use when an advanced practice clinician delivers the monthly care management service in an ambulatory surgical center under appropriate supervision.
`CQ`	Service furnished by a physician when a clinical staff member is a qualified physical therapist or occupational therapist	Use when the service involves coordination with or services furnished by qualified therapy staff under specific payer policies.
`QK`	Medical direction of two, three, or four staff physicians	Use when the billing physician medically directs multiple qualified clinicians providing components of the monthly service.
`QX`	CRNA service with qualified anesthetist absence of medical direction by an anesthesiologist	Not typically applicable; included only for related procedure contexts.
`QY`	Medical direction of one CRNA by an anesthesiologist	Not typically applicable; included for related procedural contexts.

Taxonomy Code	Specialty	Notes
`207Q00000X`	Internal Medicine	Primary clinicians managing complex chronic diseases and billing monthly comprehensive care management.
`207R00000X`	Family Medicine	Common providers delivering ongoing disease-focused care management for high-risk chronic conditions.
`208000000X`	Cardiology	Specialists commonly involved when the focus condition is cardiovascular (e.g., CHF) and contributing to care-plan development.
`363L00000X`	Nurse Practitioner	Advanced practice clinicians who frequently provide and document `G2064` services in collaboration with physicians.
`367500000X`	Clinical Nurse Specialist	Provides care coordination, patient education, and care-plan maintenance for complex chronic conditions.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`I50.32`	Chronic diastolic (congestive) heart failure	Common single high-risk condition that requires frequent medication adjustments and places the patient at risk of hospitalization; appropriate focus for `G2064`.
`I50.33`	Chronic combined systolic and diastolic heart failure	Represents advanced heart failure complexity often requiring comprehensive monthly disease-focused management.
`E11.65`	Type 2 diabetes mellitus with hyperglycemia	Diabetes with poor control can be a high-risk single condition needing intensive monthly management when it is the primary focus.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	COPD exacerbations and medication adjustments create high hospitalization risk warranting disease-focused monthly management.
`N18.4`	Chronic kidney disease, stage 4 (severe)	Advanced CKD often necessitates frequent medication and care-plan adjustments and is appropriate for single-disease comprehensive management.
`K72.90`	Chronic hepatic failure, unspecified without coma	Advanced liver disease with high complexity and hospitalization risk that may be managed under a disease-focused monthly program.
`G20`	Parkinson disease	Progressive neurologic disease with complex management needs and risk of complications; may be the target of a single-condition comprehensive care plan.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`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 required elements	May be billed for less complex, time-based chronic care management when the patient has multiple chronic conditions but not a single high-risk disease requiring `G2064`.
`99487`	Complex chronic care management services, first hour of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with required elements and high-complexity medical decision making	Used for patients with multiple complex chronic conditions requiring higher complexity care management; often coordinated with `G2064` when single-condition focus differs.
`99439`	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	Used to add time-based increments for chronic care management when additional documented time is needed beyond base services.
`99495`	Transitional care management services with moderate medical decision complexity (communication within 2 business days, face-to-face within 14 calendar days)	Often performed after hospital discharge before enrolling or concurrently with monthly comprehensive disease-focused management under `G2064`.
`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	May be used when RPM data collection and interpretation contribute to the monthly care management for the single high-risk disease.