Coverage criteria for care management services — service type, required elements, time thresholds, documentation/consent requirements.
Chronic Care Management (CCM) — general: CCM services (99490, 99491, 99437, 99439) are management and support services provided by clinical staff under the direction of a physician or other QHP or personally by a physician/QHP for patients in community or domiciliary settings. Services include establishing, implementing, revising, or monitoring a comprehensive care plan; coordinating other professionals and agencies; patient/caregiver education; medication reconciliation; and oversight of self-management.
CCM time & reporting: Code selection is based on cumulative time in a calendar month. 99490 requires at least 20 minutes of clinical staff time; 99491 is 30 minutes of physician/QHP time. 99439 (or G2058) reports additional time increments; do not report add-on codes for durations below the stated increments. Only one CCM code may be billed per patient per month.
CCM documentation & consent: Initiation must occur during a face-to-face visit with the billing practitioner. Advance consent is required and must be documented prior to providing CCM; consent must inform the patient about services, cost-sharing, single-practitioner billing, and right to stop services. A separate Comprehensive Care Plan must be documented and made available for audit and provided to the patient. Incremental and total monthly time must be documented.
Complex Chronic Care Management (Complex CCM): Complex CCM (99487; 99489 add-on) requires: multiple (2+) chronic conditions expected ≥12 months or until death; conditions placing patient at significant risk (death, acute exacerbation, functional decline); establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; and at least 60 minutes of clinical staff time directed by a physician/QHP per calendar month. Report 99489 for each additional 30-minute increment (minimum 30 additional minutes). Complex CCM <60 minutes is not reported separately.
Principal Care Management (PCM) / Comprehensive Care (G2064/G2065): PCM (99424-99427) and comprehensive care management (G2064/G2065) address a single high-risk disease. Requirements include one complex chronic condition expected ≥3 months that places the patient at significant risk, disease-specific care plan development/monitoring, frequent medication adjustments or unusually complex management, ongoing communication between relevant practitioners, and time thresholds (first 30 minutes personally by physician/QHP for 99424/G2064; additional 30-minute increments via add-on codes). Do not bill PCM concurrently with specified excluded codes per CPT guidance.
Transitional Care Management (TCM): TCM (99495, 99496) covers care transitions from facility to community (home, domiciliary, assisted living) and begins on date of discharge continuing 29 days. Required elements: interactive contact with patient/caregiver within 2 business days of discharge, and a face-to-face visit within specified timeframe with stated medical decision complexity (99495: visit within 14 days, moderate complexity OR 7 days moderate as applicable; 99496: visit within 7 days with high complexity). Non-face-to-face clinical staff activities directed by the physician/QHP complement the face-to-face visit. Only one health care professional may report TCM, and it should be reported once during the TCM period.
TCM billing & exclusions: Physicians and eligible non-physician practitioners may bill TCM only if they have primary responsibility for post-discharge care coordination; secondary consultants are not eligible. CNMs, CNSs, NPs, and PAs may furnish non-face-to-face TCM under supervision. TCM may not be billed during a post-operative global period that overlaps the TCM period, and TCM periods cannot overlap CCM periods. The place of service should reflect the face-to-face visit. The date of service is the date of the required face-to-face visit; claims need not be held until the end of the service period.
TCM documentation: Document patient's consent to participate in TCM and acknowledgement of potential cost-sharing, date of discharge, date of interactive contact, date of face-to-face visit, and details of medical decision making and its complexity (moderate or high).
Advance Care Planning (ACP): ACP (99497, 99498) is a face-to-face counseling service by a PCP physician or qualified PCP health care professional with patient/family/surrogate about advance directives; no active management of the patient's problems is undertaken during ACP time. 99497 is the first 30 minutes face-to-face; 99498 is each additional 30 minutes and must be reported with 99497. Coverage and reimbursement are subject to member benefit terms and specialty limits.
ACP documentation & limits: Before ACP delivery obtain and document patient consent and acknowledgement of any potential cost share. Document total minutes with start and end times, that the patient/surrogate/family were given opportunity to decline, and detailed content of the discussion (participants, topics, understanding, advance directive completion). ACP codes are limited to once per calendar year and not separately reimbursed with certain wellness or preventive visits; 99498 must be billed only with 99497. Reimbursement specialties and other billing exclusions apply.
Behavioral Health Integration (BHI) — General (99484): BHI (99484) is billed by the patient's PCP and covers at least 20 minutes of clinical staff time directed by a physician/QHP per calendar month for behavioral health conditions. Required elements: initial assessment/follow-up monitoring using validated rating scales; behavioral health care planning and revision as needed; facilitating/coordinating psychotherapy, pharmacotherapy, counseling, and/or psychiatric consultation; and continuity of care with a designated team member. Time and activities used to meet other reported services cannot be double-counted toward 99484.
BHI eligibility & service requirements: Eligibility: either (a) multiple (≥2) chronic conditions expected ≥12 months that place the patient at significant risk, or (b) any behavioral health/psychiatric condition being treated by the practitioner that warrants BHI. An initiating E/M, AWV, or IPPE must have occurred within 1 year prior to starting services. Beneficiary consent (written or verbal) must be obtained and documented before providing services, including information on availability, cost-sharing, single-practitioner billing, right to stop services, and permission to consult specialists. At least 20 minutes of care coordination services must be furnished in the calendar month under direction of the physician/NP/PA/CNM and by appropriate personnel.
BHI documentation: For patients meeting clinical eligibility, maintain structured patient health information in Certified EHR Technology (demographics, problems, medications, allergies) that informs the care plan. Care plans must be created/revised/monitored, made available electronically, and a copy provided to the patient/caregiver. Document beginning and ending times and total minutes in the medical record for audit readiness. Clinical staff time coordinating with the ED may be reported, but time while the patient is inpatient or in observation cannot be reported for 99484.
Psychiatric Collaborative Care Management (PCCM): PCCM (99492, 99493, 99494, G2214) is intended to be billed by the PCP and not by consultants. Required team: practitioner (physician/NP/PA/CNM) directing care; behavioral health care manager providing assessments, validated rating scales, brief psychosocial interventions, registry maintenance, and availability for face-to-face services; and a psychiatric consultant participating in regular case reviews and providing guidance. Initial month requires at least 70 minutes of BHCM activities; subsequent months require at least 60 minutes. 99492 covers initial 70 minutes; 99493 covers first 60 minutes subsequent; 99494 is add-on 30-minute increments.
PCCM consent & timing: An initiating E/M, AWV, or IPPE must have occurred within one year before starting PCCM. Beneficiary consent (written or verbal) must be obtained and documented before care coordination begins, including availability, cost-sharing, single-practitioner billing, right to stop, and permission to consult relevant specialists. Document time thresholds met each calendar month and maintain registry tracking and weekly caseload consultation records.