CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy Transitional Care, Chronic Care and Complex Chronic Care Management

Governance of payment and coverage guidelines for Transitional Care Management (TCM), Chronic Care Management (CCM), Complex Chronic Care Management (CCCM) and principal care/complex disease management codes for Blue Cross Blue Shield - Rhode Island members; applies to Medicare Advantage and Commercial products as described.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy Transitional Care, Chronic Care and Complex Chronic Care Management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2019

Next Review DateN/A

Key ActionFor member-specific benefits, call the provider call center or submit comments via the envelope icon.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2019-05-01Effective date shown

2023-10-04Policy last updated

Medicare Advantage, CommercialProducts addressed

Multiple (e.g., 99495-99496, 99490-99496, 99487)CPT codes referenced

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Coverage and Payment Criteria

inv-01: Coverage criteria for TCM/CCM/CCCM

Coverage and payment rules, by product type and service:

TCM services are covered when payment guidelines are met; the 30-day TCM period begins on the date of discharge to home and continues for 29 days. Eligible discharge settings include inpatient acute care hospital, inpatient psychiatric hospital, skilled nursing facility, long term care hospital, inpatient rehabilitation facility, partial hospitalization, and hospital outpatient observation. Only one health care professional may report TCM services; report TCM once per member during the TCM period. The face-to-face visit required by the CPT code is part of TCM and should not be reported separately. TCM may not be billed during a post-operative global period for the same practitioner and may not be billed with specified services (e.g., home health/hospice supervision G0181/G0182, care plan oversight, ESRD services).

Communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge is required for TCM.

TCM face-to-face timing (by CPT code)

99495: communication within 2 business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit within 14 calendar days of discharge.
99496: communication within 2 business days of discharge; medical decision making of high complexity during the service period; face-to-face visit within 7 calendar days of discharge.

Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM) services are covered. For Medicare Advantage many CCM/CCCM codes are covered and separately reimbursed; for Commercial products CCM/CCM and CCCM services are covered but generally not separately reimbursed as specified by product.

ALL of the following

99490: first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
99487: Complex CCM — 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month; moderate or high complexity medical decision making.
Additional CCM/CCCM add-on codes (e.g., 99437, 99439, 99489) represent specified increments of additional clinical staff or physician/QHP time per month as described by the CPT code.

Principal care management codes (99424–99427) are listed with required elements (development and monitoring of a disease-specific care plan and specified time increments). Coverage and separate reimbursement vary by product; some PCM codes are covered but not separately reimbursed for Commercial products as noted in product-specific sections.

Benefits may vary between groups and contracts; refer to the Subscriber Agreement or Benefit Booklet for applicable office visit coverage and member-specific benefits.

Prior authorization: Not applicable. Medical criteria: Not applicable.

Relevant CPT Codes and Timing Rules

Covered CPT CodesCPTCovered

99495	Transitional Care Management Services - communication within 2 business days; moderate complexity MDM; face-to-face within 14 days
99496	Transitional Care Management Services - communication within 2 business days; high complexity MDM; face-to-face within 7 days
99490	Chronic Care Management - first 20 minutes of clinical staff time per month; multiple chronic conditions
99487	Complex Chronic Care Management - 60 minutes of clinical staff time per month; moderate or high complexity MDM
99489	Complex Chronic Care Management - additional 30 minutes of clinical staff time
99424	Principal care management - first 30 minutes provided personally by physician or QHP per month (single high-risk disease)
99425	Principal care management - each additional 30 minutes provided personally by physician or QHP per month
99426	Principal care management - first 30 minutes of clinical staff time directed by physician or QHP per month
99427	Principal care management - each additional 30 minutes of clinical staff time directed by physician or QHP per month
99437	Chronic care management - each additional 30 minutes by physician or QHP per month

1–10 of 11

1/2

Covered but not separately reimbursed (Commercial where specified)CPT

99425

Principal care management - each additional 30 minutes provided personally by physician or QHP per month (listed as covered but not separately reimbursed for some Commercial products)

TCM face-to-face timing

99495 face-to-face timingFace-to-face visit must occur within 14 calendar days of discharge

99496 face-to-face timingFace-to-face visit must occur within 7 calendar days of discharge

Required communication timeframeCommunication with patient and/or caregiver within 2 business days of discharge (applies to both 99495 and 99496)

CCM/CCCM minimum time

99490 minimum timeFirst 20 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month

99487 minimum time60 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month

Provider Requirements and Contacts

Prior Authorization

Prior authorization — Not applicable

Prior authorization is not required for services covered by this policy.

Note

Provider contact and comments

For member-specific benefits or eligibility questions, call the provider call center. To submit comments about this policy, click the envelope icon on the policy page.

Member benefits and eligibility are determined by the member's subscriber agreement, member certificate, and/or employer agreement.
This policy is informational only and not a guarantee of payment.

Definitions and Policy Scope Notes

Chronic Care Management (CCM)

DefinitionServices for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until death, requiring a comprehensive care plan that is established, implemented, revised, or monitored

Staff time requirementCodes define required clinical staff time per month (e.g., 99490 first 20 minutes; 99487 60 minutes)

Care planA comprehensive care plan must be established, implemented, revised, or monitored as part of CCM/CCCM services

Transitional Care Management (TCM)

DefinitionServices provided following discharge from specified inpatient settings that require communication with the patient and/or caregiver within 2 business days and a face-to-face visit within the CPT-specified timeframe

Communication requirement