ModifiedHighmark PennsylvaniaPolicy RP-043
Care Management
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Defines how Highmark Pennsylvania reimburses providers for care management services (CCM, CCCM, PCM, TCM, ACP, PCCM, BHI) and who it affects (providers contracted with the Plan in designated markets).
Policy Summary
PayerHighmark Pennsylvania
PolicyCare Management
Policy CodePolicy RP-043
Change TypeCodes addedformatting and definitional clarifications
Effective DateMay 25, 2026
Next Review Date
Key ActionSelect care management codes based on required time thresholds and document consent and comprehensive care plans.
SourceLink
POLICY UPDATE CHANGES
Added codes 99497 and 99498.
Streamlined direction and added definitions for clarity and applied to new policy template.
1one CCM code billed per patient per month (max)
29 daysTCM service period post-discharge
99497/99498APC codes added
70 / 60PCCM initial / subsequent minutes
20 minBHI minimum monthly time
Coverage Criteria for Care Management Services
Reimbursement criteria for care management codes
Care management services are reimbursed based on CPT-defined time and service requirements; providers must follow CPT guidance and Plan payment rules.
Provider follows CPT code descriptors and Plan payment guidelines when selecting care management codes (time- and service-based code selection).
Time used to meet criteria for one care management code may not be double-counted to meet criteria for another reported service; follow CPT reporting and mutual-exclusion rules.
Care management coverage criteria
Coverage and billing criteria, documentation requirements, and limits for CCM, complex CCM, PCM, and TCM.
Clinical eligibility: CCM and complex CCM apply to patients with multiple chronic conditions expected to last at least 12 months or until death and that place the patient at significant risk; PCM applies to a single complex chronic condition expected >=3 months.
Consent and initiation: Obtain and document advance consent prior to delivery of CCM services; initiation of CCM must occur during a face-to-face visit with the billing practitioner.
Comprehensive Care Plan: Document a separate Comprehensive Care Plan after initiation (must be available for audit) and provide a copy to the patient; document incremental and total time each month for CCM/CCCM.
Single-biller rule and billing limits: Only one practitioner may bill CCM/PCCM/BHI care coordination services and be paid for those services per patient per calendar month; practitioners may report CCM codes at conclusion of service period or when time threshold met; unit maximums and add-on rules apply as specified by CPT and policy.
TCM specifics: TCM requires communication within 2 business days of discharge, a face-to-face visit within required timeframe (7 or 14 days depending on complexity), and documentation of specified elements; coverage is subject to member benefit terms.
Practice capabilities: Care management programs should provide 24/7 access, continuity with designated team member, timely follow-up after ED/facility discharge, use EHR for data, and engage patients/caregivers per policy requirements.
Reporting timing and exclusions: Complex CCM should generally be reported at the conclusion of the service period due to MDM requirements; numerous mutually exclusive reporting rules and excluded code combinations are listed in the policy and must be followed.
TCM criteria
Transitional Care Management coverage and documentation requirements
Provider eligibility: Physicians and non-physician practitioners may bill TCM only if they have primary responsibility for post-discharge care coordination; secondary consultants are not eligible.
Single-reporting limitation: Only one health care professional may report TCM services and TCM should be reported only once during the TCM period.
Global period and concurrent service exclusions: TCM will not be paid if any part of the 30-day TCM period falls within a post-operative global period billed by the same practitioner; when reporting TCM, may not also report chronic care management or specified other services per CPT/policy exclusions.
Required elements and documentation: Document discharge date, date of interactive contact (within 2 business days), date of the face-to-face visit (face-to-face visit date is the date of service reported), and the level of medical decision making (moderate or high).
Service composition and timing: TCM commences on discharge date and continues for 29 days and is comprised of one face-to-face visit within specified timeframes plus non-face-to-face services performed by physician/QHP or licensed clinical staff under direction.
ACP criteria
Advance Care Planning coverage and billing limitations
Consent: Before delivery of ACP services, patient consent must be obtained and documented in the medical record; document acknowledgement of potential cost-sharing as applicable.
Billing limits: ACP reimbursement is limited to once per calendar year and limited to PCP specialties (including NPs and PAs); do not report 99497/99498 on the same day as Medicare AWV (G0438/G0439) or preventive medicine visits for separate reimbursement; certain high-intensity codes are also excluded from same-day reporting.
Documentation: Record total minutes with begin/end times, evidence that patient/surrogate/family were offered opportunity to decline, and details of the discussion per policy.
PCCM and BHI criteria
Psychiatric Collaborative Care Management and Behavioral Health Integration criteria
Billing entity: PCCM and BHI services are intended to be billed by the patient's PCP (or reporting QHP) and not by consulting providers; all practice expenses are included in PCP reimbursement and only one practitioner may be paid per calendar month.
Team composition (PCCM): A PCCM team must include a directing practitioner (physician/NP/PA/CNM), a behavioral health care manager, and a psychiatric consultant with defined responsibilities (assessment, registry, weekly caseload consultation, brief interventions).
Consent: Beneficiary consent must be obtained (during/after initiating visit and before care coordination) and documented; documentation must include availability, cost-sharing, right to stop, and permission to consult specialists.
Time thresholds
Documentation and program elements: Document begin/end times and total minutes for audit; BHI/PCCM programs should use registries, validated scales, EHR documentation, 24/7 access, comprehensive care plans, care transition management, and other required service elements per policy.
Care management coverage criteria
Coverage and billing stance for care management codes and requirements
General stance: Care management services (CCM, CCCM, PCM, TCM, ACP, PCCM, BHI) are reimbursed when CPT-defined clinical time, documentation, and model-specific requirements are met; follow Plan rules and member benefit terms.
CCM eligibility and single-biller rule: CCM codes (99490, 99491, 99437, 99439) may be reported for qualifying chronic care management services; only one CCM code may be billed per patient per calendar month by a single practitioner; initiation requires a face-to-face visit and documented patient consent.
Complex CCM: Complex CCM (99487, 99489) requires >=2 chronic conditions expected >=12 months, significant risk, establishment/substantial revision of a comprehensive care plan, moderate/high MDM, and at least 60 minutes clinical staff time per month as base; document care plan and total/incremental time each month.
PCM: Principal Care Management (99424-99427) applies to a single high-risk disease expected >=3 months with disease-specific care plan; apply CPT time thresholds and add-on rules per policy.
Documentation requirements: Comprehensive Care Plan must be documented separately and provided to patient; incremental/total monthly time must be recorded; verbal/written consent required prior to CCM services and patient may stop services effective end of calendar month after request.
Billing conflicts and exclusions: Numerous mutually exclusive and excluded code combinations exist (see policy lists); ensure compliant reporting and do not double-count time across services.
Transitional Care Management (TCM) criteria
Eligibility and required elements for reporting TCM codes 99495 and 99496.
Interactive contact: Communication (direct contact, telephone, or electronic) with the patient and/or caregiver within 2 business days of discharge is required.
Face-to-face timing
Documentation elements: At minimum, document evidence of patient consent to participate, date of discharge, date of interactive contact, date of face-to-face visit, and details/level of medical decision making (moderate or high) across the service period.
Exclusions and overlap: TCM is not payable if any part of the 30-day TCM period falls within a global surgical period billed by the same practitioner; TCM and chronic care management periods cannot overlap.
Single-reporting rule: Only one health care professional may report TCM services and TCM should be reported only once during the TCM period; the date of service reported is the date of the required face-to-face visit.
Advance Care Planning (ACP) criteria
Requirements for reporting ACP codes 99497 and 99498.
Consent: Patient consent must be obtained and documented prior to performing ACP services.
Documentation: Record total minutes with beginning and ending times, note that patient/surrogate/family were offered opportunity to decline, and capture details of the discussion per documentation requirements.
PCCM and BHI criteria
Eligibility, team composition, consent, and service elements for psychiatric collaborative care and behavioral health integration services.
Eligibility and billing entity: PCCM/BHI are intended to be billed by the patient's PCP (or reporting QHP); patient must have an eligible behavioral health condition (PCCM) or meet chronic condition criteria (BHI).
Time requirements
Consent: Beneficiary consent must be obtained and documented before provision of care coordination services and must include information on availability, cost-sharing, single-provider payment, right to stop, and permission to consult specialists.
Service elements: PCCM/BHI services include registry use, validated rating scales, brief evidence-based interventions, behavioral health care planning, coordination and follow-up after ED/hospital, continuity with a designated team member, 24/7 access mechanisms (for BHI), and other program elements described in policy.
Documentation: Record beginning/ending times and total minutes for audit; maintain registry and documentation supporting required program activities and care plan elements.
Reference and History
References and historical code changes relevant to coverage and billing for BHI care management services.
Policy references: Providers should follow the current AMA CPT Manual E/M section and CMS Behavioral Health Integration and TCM/ACP MLN materials and fact sheets referenced in the policy.
Resources: Policy cites CMS MLN resources for Cognitive Assessment and Care Planning, Care Coordination Services and Payment for RHCs/FQHCs, Advance Care Planning, Behavioral Health Integration, and Transitional Care Management (links provided in policy references).
History: The policy history documents implementation and code additions/removals over time (examples: addition of 99484, 99492–99494 in 4/2020; additions/removals of various G-codes in 2020–2022; policy update entries through 5/2026).
CPT/HCPCS Codes and Time-Based Reporting
Chronic Care Management (CCM)CPTCovered
Principal Care Management (PCM)CPTCovered
Transitional Care Management (TCM)CPTCovered
Psychiatric Collaborative Care Management (PCCM)mixedCovered
Behavioral Health Integration (BHI)CPTCovered
| 99484 | Behavioral Health Integration Care Management - at least 20 minutes clinical staff time per calendar month |
Care management codes and descriptionsCPTCovered
| 99490 | Chronic care management; first 20 minutes clinical staff time directed by a physician/QHP, per calendar month |
| 99491 | Chronic care management provided personally by a physician/QHP; first 30 minutes per calendar month |
| 99437 | Each additional 30 minutes of physician/QHP time for CCM |
| 99439 | Each additional 20 minutes of clinical staff time for CCM (add-on to 99490) |
| 99487 | Complex chronic care management; first 60 minutes clinical staff time per calendar month with moderate/high complexity MDM |
| 99489 | Each additional 30 minutes clinical staff time for complex CCM (add-on to 99487) |
| 99424 | Principal care management; first 30 minutes personally by physician/QHP for a single high-risk disease |
| 99425 | Each additional 30 minutes personally by physician/QHP for PCM |
| 99426 | Principal care management provided by clinical staff; first 30 minutes |
| 99427 | Each additional 30 minutes clinical staff for PCM (add-on to 99426) |
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Advance Care Planning (ACP) - detailedCPTCovered
Psychiatric Collaborative Care Management (PCCM) - detailedCPTCovered
| 99492 | Initial psychiatric collaborative care management, first 70 minutes in first calendar month |
| 99493 | Subsequent psychiatric collaborative care management, first 60 minutes in subsequent month |
| 99494 | Each additional 30 minutes in a calendar month for PCCM (add-on) |
| G2214 | Initial or subsequent PCCM, first 30 minutes in a month of BH care manager activities |
Behavioral Health Integration (BHI) - detailedCPTCovered
| 99484 | Behavioral health integration care management, at least 20 minutes of clinical staff time directed by a physician or QHP per calendar month |
Care management and TCM codes (consolidated)CPTCovered
| 99490 | Chronic care management services; first 20 minutes clinical staff time per calendar month |
| 99439 | Each additional 20 minutes clinical staff time (with 99490), up to twice per month |
| 99491 | CCM personally provided by physician/QHP; first 30 minutes per calendar month |
| 99437 | Each additional 30 minutes physician/QHP time (with 99491) |
| 99487 | Complex CCM; first 60 minutes clinical staff time, moderate/high MDM |
| 99489 | Each additional 30 minutes clinical staff time (with 99487) |
| 99424 | Principal care management; first 30 minutes personally by physician/QHP |
| 99425 | Each additional 30 minutes physician/QHP time (with 99424) |
| 99426 | Principal care management; first 30 minutes clinical staff |
| 99427 | Each additional 30 minutes clinical staff time (with 99426) |
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Transitional Care Management (TCM) - alternate refsCPTCovered
Advance Care Planning (ACP) - alternate refsCPTCovered
Psychiatric Collaborative Care Management - alternate refsCPTCovered
| 99492 | Initial psychiatric collaborative care management, first 70 minutes in first calendar month |
| 99493 | Subsequent psychiatric collaborative care management, first 60 minutes in subsequent month |
| 99494 | Each additional 30 minutes in a calendar month for PCCM (add-on) |
| G2214 | Initial or subsequent PCCM, first 30 minutes in a month of BH care manager activities |
Behavioral Health Integration - alternate refsCPTCovered
| 99484 | Behavioral health integration care management services, at least 20 minutes of clinical staff time directed by a physician or QHP per calendar month |
BHI and care management related codes (historical additions/removals)CPT | HCPCS | mixed
| 99484 | Behavioral health integration care management service (example - added in 4/2020) |
| 99492 | Initial psychiatric collaborative care management (example - added in 4/2020) |
| 99493 | Subsequent psychiatric collaborative care management (example - added in 4/2020) |
| 99494 | Additional psychiatric collaborative care management (example - added in 4/2020) |
| 99487 | Complex chronic care coordination (example - eligibility noted for WV and PA in 4/2020) |
| 99489 | Complex chronic care management add-on (example - eligibility noted for WV and PA in 4/2020) |
| 99490 | Chronic care management (example - eligibility noted for WV and PA in 4/2020) |
| 99491 | Chronic care management, complex (example - eligibility noted for WV and PA in 4/2020) |
| G2058 | Behavioral health integration code (removed in 3/2021 per history) |
| G2064 | Behavioral health integration code (removed in 6/2022 per history) |
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Time-based reporting thresholds — overview
General ruleCodes are reported based on minimum minutes of clinical staff or physician/QHP time per calendar month or per service episode as specified for each CPT code.
CCM clinical staff threshold99490 requires at least 20 minutes of clinical staff time per calendar month (30 days).
Physician/QHP CCM threshold99491 requires at least 30 minutes of physician or other qualified health care professional time per calendar month.
CCM add-ons limit99439 (additional 20-minute increments) may be reported up to twice per calendar month (max 60 minutes total).
Time-based reporting thresholds — specific minutes and add-on guidance
CCM base and add-on minutes99490 = 20 minutes clinical staff; +99439 = each additional 20 minutes (reportable up to 2 times per month).
Physician CCM and add-on99491 = 30 minutes physician/QHP personal time; +99437 = each additional 30 minutes physician/QHP time (no unit limit).
Complex CCM minutes99487 = first 60 minutes clinical staff time per month; +99489 = each additional 30 minutes clinical staff time per month (no unit limit).
PCM minutes and add-ons99424 = at least 30 minutes physician/QHP personal time; +99425 when at least 90 minutes; 99426/99427 mirror clinical staff 30-minute increments.
PCCM minimum time — initial and subsequent month thresholds
Initial month threshold99492 (PCCM initial) requires at least 70 minutes of behavioral health care manager activity in the first calendar month.
Subsequent month threshold99493 (PCCM subsequent) requires at least 60 minutes of behavioral health care manager activity in subsequent calendar months.
Team and documentation linkPCCM requires a directing practitioner, behavioral health care manager, psychiatric consultant, and documented beneficiary consent and registry use.
BHI minimum time
BHI monthly minimum99484 requires at least 20 minutes of clinical staff time per calendar month directed by a physician or other QHP.
Billing entity99484 is reported by the supervising physician or other qualified health care professional (PCP billing expectation).
Documentation and elementsBHI requires an initiating E/M/AWV/IPPE within prior year, beneficiary consent, structured EHR elements, and continuity of care elements.
Time-based reporting thresholds and typical unit counts
Example: CCM minutes to units20–39 minutes = 99490 (unit max 1); 40–59 minutes = 99490 + 99439 x1; 60+ = 99490 + 99439 x2.
Example: Complex CCM mapping60–89 minutes = 99487 x1; 90–119 minutes = 99487 x1 + 99489 x1; additional 30-minute increments = additional 99489 units.
Example: PCM mapping (physician/QHP)30–59 minutes = 99424 x1; 60–89 minutes = 99424 x1 + 99425 x1; 90–119 minutes = 99424 x1 + 99425 x2.
Example: PCM mapping (clinical staff)30–59 minutes = 99426 x1; 60–89 minutes = 99426 x1 + 99427 x1; 120+ minutes = 99426 x1 + 99427 x2 (per table examples).
Time thresholds for collaborative care
PCCM initial/subsequentInitial PCCM = at least 70 minutes in first calendar month (99492); Subsequent PCCM = at least 60 minutes in subsequent months (99493).
BHI baselineBHI (99484) requires at least 20 minutes of clinical staff time per calendar month and is billed by the PCP/QHP.
Add-on usage99494 (PCCM add-on) reported for each additional 30-minute increment in a calendar month; G2214 represents first 30 minutes in some reporting scenarios.
TCM period
TCM service periodTCM commences on the date of discharge and continues for the next 29 days (TCM period).
Required contactCommunication (direct contact, telephone, electronic) with the patient and/or caregiver must occur within 2 business days of discharge for TCM (99495/99496).
Face-to-face timingFace-to-face visit timing differentiates codes: 99495 typically with visit within 14 days (moderate complexity); 99496 within 7 days (high complexity).
Provider Billing, Consent, and Documentation Requirements
Billing Rule
Prior authorization / billing guidance
Select care management CPT codes based on time thresholds in a calendar month; follow current AMA CPT guidance when assigning date of service and counting time. Reimbursement follows Plan payment guidelines.
Documentation Required
Preconditions, consent, and timing for billing care management
Obtain and document beneficiary consent BEFORE delivery of care coordination services; initiation of CCM must occur during a face-to-face visit with the billing practitioner. Document comprehensive care plan and monthly time. Consent may be written or verbal but must be recorded in the medical record.
- Consent must include availability and content of services, applicable cost-sharing, that only one practitioner may furnish and be paid per calendar month, right to stop services (effective end of month), and permission to consult specialists. (chunk 27, 48, 87)
- Comprehensive Care Plan must be separate from other visit documentation, provided to the patient, and include problem list; expected outcomes; measurable goals; cognitive/functional assessments; interventions and responsible individuals; medication/symptom management; environmental and caregiver assessments; coordination with outside resources; schedule for review. Document incremental and total time each month. (chunk 27, 66)
- CCM initiation must occur during a face-to-face visit with the billing practitioner; the practitioner can bill only one CCM code per patient per calendar month. (chunk 27, 65)
Documentation Required
Transitional Care Management timing requirements
Contact the patient or caregiver within 2 business days of discharge and document the contact. Provide the required face-to-face visit within the timeframe for the code billed (99495: within 14 days; 99496: within 7 days). Report date of service as the date of the required face-to-face visit; TCM commences on date of discharge and continues 29 days.
- Document date of discharge, date of interactive contact, date of face-to-face visit, and level of medical decision making (moderate or high). (chunk 75)
- Date of service should be reported as date of required face-to-face visit and claim may be filed without holding until the end of the TCM period. (chunk 75)
- Only one health care professional may report TCM services and TCM is reportable only once during the TCM period. (chunk 37, 75)
Billing Rule
ACP / PCCM / BHI billing constraints
Advance Care Planning (99497/99498), PCCM (99492–99494, G2214), and BHI (99484) have specific billing constraints — frequency limits, specialty restrictions, and same-day exclusions must be observed.
- ACP: 99497/99498 — limited to once per calendar year; not payable same day as G0438/G0439 or preventive medicine codes; 99498 reported only with 99497; billed specialties limited to primary care. (chunk 79)
- BHI (99484): requires ≥20 minutes clinical staff time per month; beneficiary consent required; intended for PCP billing; do not report 99484 with PCCM codes in same month. (chunk 46, 85, 86, 87)
- PCCM (99492–99494, G2214): intended for PCP billing; follow elements and use 99494 with 99492/99493 as applicable. (chunk 81, 46)
Billing Rule
Consent and single-provider payment rule
Beneficiary consent is required before initiating PCCM, BHI, or CCM and must be documented. Only one practitioner may furnish and be paid for care coordination services (CCM, BHI, PCCM) or TCM per patient per calendar month (single-biller rule).
- Document beneficiary consent in the medical record prior to delivering services; include right to stop services (effective end of calendar month) and cost-sharing information. (chunk 27, 48, 87)
- When multiple practitioners participate in care coordination, only the designated billing practitioner (typically the PCP or primary coordinator) may be reimbursed for the monthly care management service. (chunk 27, 46, 85)
Note
Coding and Authorization Guidance
Follow the current AMA CPT Manual (E/M section) and CMS Behavioral Health Integration guidance for coding, code selection, and reporting rules. Adhere to CPT rules regarding mutually exclusive services, global periods, and counting of time across services.
- Do not double-count time used to meet criteria for other reported services when calculating minutes for BHI, CCM, or PCCM; follow CPT exclusions (e.g., overlapping global periods, prohibited concurrent reporting). (chunk 65, 75, 85)
- Use cited CMS and AMA resources for operational coding questions and for accurate application of reporting rules. (chunk 90)
Key Definitions
Chronic Care Management (CCM)
CCM definitionChronic Care Management (CCM): oversight and educational activities by health care professionals to help patients with chronic diseases; time- and service-based CPT rules apply (e.g., 99490, 99491).
CCM code setCommon CCM CPT codes: 99490 (clinical staff 20 min), 99491 (physician/QHP 30 min), plus add-ons 99439 and 99437.
Service intentCCM services encompass care coordination, patient education, and oversight to improve management of chronic conditions.
Complex Chronic Care Management (CCCM)
CCCM definitionComplex Chronic Care Management (CCCM): requires at least 60 minutes of clinical staff time per calendar month under direction of a physician/QHP and involves moderate or high medical decision making (99487; +99489 add-ons).
Unitization guidanceReporting examples: 60–89 min = 99487 x1; 90–119 min = 99487 x1 + 99489 x1; additional 30-minute increments use additional 99489 units.
Clinical requirementsApplies to patients with multiple (two or more) chronic conditions expected to last ≥12 months and placing patient at significant risk; comprehensive care plan required.
Principal Care Management (PCM)
PCM definitionPrincipal Care Management (PCM): services focused on a single complex chronic condition expected to last at least 3 months and includes establishing, implementing, revising, or monitoring a disease-specific care plan.
PCM time rulesPhysician/QHP personal time: 99424 = first 30 minutes; +99425 = additional 30-minute increments (e.g., ≥90 minutes triggers add-on). Clinical staff: 99426/99427 mirror 30-minute increments.
Reporting examples30–59 min = 99424 or 99426 x1; 60–89 min = 99424 x1 + 99425 x1 (physician) or 99426 x1 + 99427 x1 (clinical staff); higher totals follow table guidance.
Transitional Care Management (TCM)
TCM definitionTransitional Care Management (TCM): services following discharge that commence on the date of discharge and continue for 29 days, combining a required face-to-face visit within specified timeframes and non-face-to-face services (99495, 99496).
Code differentiation99495 = TCM with moderate complexity (face-to-face within 14 days); 99496 = TCM with high complexity (face-to-face within 7 days).
Required documentationDocument discharge date, date of interactive contact within 2 business days, date of face-to-face visit, and complexity of medical decision making.
Psychiatric Collaborative Care Management (PCCM)
PCCM modelPsychiatric Collaborative Care Management (PCCM): team-based model where a behavioral health care manager provides care under direction of a treating physician/QHP in consultation with a psychiatric consultant; involves registry, validated scales, and weekly consultation.
Team rolesCore team: directing practitioner (physician/NP/PA/CNM), behavioral health care manager (master's/doctoral-level or specialized training), and psychiatric consultant.
Billing expectationPCCM services are intended to be billed by the patient's PCP and require documented beneficiary consent and initiation visit within prior year.
Behavioral Health Integration (BHI)
BHI definitionBehavioral Health Integration (BHI): team-based primary care and behavioral health collaboration for defined populations; 99484 is reported for at least 20 minutes of clinical staff time per calendar month directed by a physician/QHP.
Eligibility optionsBHI may apply to patients with multiple chronic conditions or any behavioral health condition warranting BHI services as judged by practitioner.
Service elementsRequires initiating E/M/AWV/IPPE within prior year, consent, structured EHR use, assessment and care planning, coordination, and continuity of care.
Qualified Healthcare Professional (QHP)
QHP definitionQualified Healthcare Professional (QHP): an individual qualified by education, training, licensure/regulation and facility privileging who performs professional services within scope of practice and independently reports those services (distinct from clinical staff).
ExamplesQHPs include physicians, NPs, PAs, and others authorized to independently report professional services per policy definitions.
Role in care managementQHPs direct clinical staff activities for CCM/CCCM/BHI and personally furnish services when physician/QHP time thresholds apply (e.g., 99491, 99424).
Care management
Care management termCare management: a range of activities intended to improve patient care and reduce need for medical services by helping patients and caregivers manage health conditions through coordination, education, and planning.
ComponentsIncludes care planning, coordination with community resources, patient/caregiver education, monitoring, and facilitating access to services.
Policy purposeThis policy provides the Plan's reimbursement direction for these services and defines time, documentation, and billing rules.
Advance Care Planning (ACP)
ACP definitionAdvance Care Planning (ACP): face-to-face counseling and discussion between a physician or other qualified health care professional and a patient/family/surrogate about advance directives; reported with 99497 (first 30 minutes) and 99498 (additional 30-minute increments).
Consent and documentationPatient consent must be obtained and documented before ACP; document total time with begin/end times and details of discussion; ACP may be subject to member cost-sharing.
Billing limitsACP codes limited to once per calendar year and not separately reimbursed when performed same day as Medicare AWV or preventive medicine; 99498 must be reported with 99497.
Transitional Care Management (TCM) — alternate
TCM alternate definitionTransitional Care Management (TCM): services provided following discharge that commence on the date of discharge and continue for 29 days, combining face-to-face and non-face-to-face components (99495/99496).
Required elementsTCM requires communication within 2 business days of discharge, a timely face-to-face visit (7 or 14 days depending on complexity), and documentation of discharge date and contacts.
Billing constraintsOnly one health care professional may report TCM services and TCM should be reported only once during the TCM period; coverage subject to member benefit terms.
Chronic Care Management (CCM) — alternate
CCM alternate definitionChronic Care Management (CCM): oversight and educational activities by health care professionals to help patients with chronic diseases; CPT time- and service-based code rules apply (e.g., 99490 = 20 min clinical staff).
Patient eligibilityTypically applies to patients with multiple chronic conditions expected to last ≥12 months or until death and placing patient at significant risk.
Documentation requirementComprehensive care plan must be established/maintained and time spent each month documented for auditability.
Principal Care Management (PCM) — alternate
PCM alternate definitionPrincipal Care Management (PCM): management services for a single complex chronic condition expected to last at least 3 months, including a disease-specific care plan and ongoing coordination.
Time and reportingPhysician/QHP time thresholds (99424/99425) and clinical staff thresholds (99426/99427) follow CPT tables for increments and unit counts.
Overlap rulesPCM mirrors CCM reporting constraints and includes lists of mutually exclusive codes that cannot be reported concurrently per policy tables.
Qualified Healthcare Professional (QHP) — alternate
QHP alternate definitionQualified Healthcare Professional (QHP): individual qualified by education, training, licensure/regulation and facility privileging who performs professional services within scope of practice and independently reports those services; QHPs are distinct from clinical staff.
Role exampleQHPs include physicians, nurse practitioners, physician assistants, and others authorized to independently report services and direct clinical staff.
Use in policyQHP personal time thresholds apply to specific codes (e.g., 99491, 99424) where physician/QHP personal work is required for reporting.
Advance directive
Advance directive definitionAdvance directive: a document appointing an agent and/or recording patient wishes about future medical treatment if decisional capacity is lost (e.g., Health Care Proxy, Durable Power of Attorney, Living Will, MOLST).
Relation to ACPACP discussions may include completion or review of advance directive forms as part of the face-to-face counseling (99497/99498).
DocumentationWhen ACP performed, document whether advance directive was offered/completed and include details in record per ACP documentation requirements.
BHI — alternate
BHI alternate definitionBehavioral Health Integration (BHI): team-based primary care and behavioral health collaboration using structured tools and care planning for defined populations; 99484 reports at least 20 minutes clinical staff time per calendar month.
Documentation elementsBHI requires structured EHR recording, registry use for some patients, care planning, brief interventions, and continuity with a designated team member.
Billing restrictionDo not report 99484 in conjunction with PCCM codes (99492/99493/99494) in the same calendar month; time used for other reported services cannot be double-counted toward 99484 criteria.
PCCM — alternate
PCCM alternate definitionPCCM: behavioral health care manager-led services under direction of treating physician/QHP and consultation with psychiatric consultant; reported with codes 99492/99493/99494/G2214 based on time per calendar month.
Consent requirementBeneficiary consent must be obtained during or after the initiating visit and documented prior to provision of PCCM services.
Service elementsIncludes outreach/engagement, validated rating scales, individualized treatment plan, registry tracking, weekly caseload consultation, and brief evidence-based interventions.
CCM — short label
CCM short labelCCM = Chronic Care Management (e.g., 99490, 99491; time- and service-based).
Typical minutesKey minutes: 20 minutes clinical staff (99490); 30 minutes physician/QHP (99491).
Add-on codesAdd-ons include 99439 (clinical staff 20-min increments) and 99437 (physician 30-min increments).
TCM — short label
TCM short labelTCM = Transitional Care Management services (99495, 99496) covering 29 days post-discharge.
Key elementsIncludes required communication within 2 business days and a timely face-to-face visit within 7 or 14 days depending on complexity.
Single reportingOnly one practitioner may report TCM and it should be reported only once during the TCM period.
ACP — short label
ACP short labelACP = Advance Care Planning (99497 first 30 minutes; 99498 additional time).
Billing frequencyLimited to once per calendar year and subject to documentation and same-day service restrictions.
Documentation noteDocument total minutes with start/end times and details of discussion; obtain consent prior to service.
PCM — short label
PCM short labelPCM = Principal Care Management for a single complex chronic condition (codes 99424-99427).
Time thresholds30-minute base units for physician/QHP or clinical staff with add-ons for additional 30-minute increments per CPT guidance.
Reporting examplesTables provide unit examples mapping minutes to 99424/99425 (physician) and 99426/99427 (clinical staff).
Transitional Care Management (TCM) — services for transitions
TCM for moderate/high complexityTCM services are for patients whose medical/psychosocial problems require moderate or high complexity medical decision-making during transitions from facility to community; reported with 99495 (moderate) or 99496 (high).
29-day periodServices commence on discharge date and continue for 29 days; include one face-to-face visit within specified timeframe and required non-face-to-face activities.
Documentation essentialsMinimum documentation: discharge date, date of interactive contact within 2 business days, date of face-to-face visit, and level of MDM.
Advance Care Planning (ACP) — face-to-face counseling
ACP face-to-face counselingAdvance Care Planning involves face-to-face counseling and discussion between a PCP or QHP and patient/family/surrogate about advance directives, reported with 99497 (first 30 minutes) and 99498 (additional 30 minutes).
Consent requirementPatient must provide consent before ACP and that consent must be documented in the medical record.
Documentation detailsDocument total time with start/end times, that patient was offered opportunity to decline, and discussion details including any forms completed.
PCCM / BHI — team-based care models
PCCM/BHI team-based modelsPCCM and BHI are team-based care models led by the PCP or QHP involving care managers and psychiatric consultants for behavioral health conditions; codes and time thresholds differ (99492/99493/99494/G2214 for PCCM; 99484 for BHI).
Overlap and billing rulesPCCM and BHI intended to be billed by the PCP; do not report 99484 with PCCM codes in same calendar month; time used for other reported services cannot be double-counted toward these codes.
Consent and initiationBeneficiary consent required during/after initiating visit and before provision of services; initiating visit must have occurred within prior year.
BHI Care Management
BHI care management elementsBHI care management includes structured reassessment, comprehensive care planning, registry use for some patients, brief interventions, care coordination, and continuity with a designated care team member.
Clinical staff roleAt least 20 minutes of clinical staff time per calendar month directed by a physician/QHP is required for 99484.
Operational requirementsInitiating E/M/AWV/IPPE within prior year is required before commencing BHI; documentation must be available for audit per policy guidance.
Policy Revision History and References
2026-05-25material_code_additionLatest
Added Advance Care Planning CPT codes 99497 and 99498 to the policy (May 2026 update).
2026-05operational_revision
Applied operational formatting and definitional clarifications to streamline direction and align with the new policy template (May 2026 update).
2023-01-01note_added
Added a policy-specific note for G0323 (January 2023).
2022-06removal
Removed HCPCS codes G2065 and G2064 and updated advisory reference links (June 2022).
2022-01-01code_additions_and_region_update
Added PCM and prolonged E/M related CPT codes (99424, 99425, 99426, 99427, 99437) and added Delaware Medicare Advantage applicability (January 2022).
2021-11scope_update
Added New York region applicability to the policy (November 2021).
2021-03code_changes
Removed code G2058 and added codes 99439 and G2214 (March 2021 update).
2020-04code_additions
Added codes 99484, 99492, 99493 and 99494 for eligibility across all regions and expanded eligibility for 99487, 99489, 99490 and 99491 to WV and PA (April 2020).
2020-01-01code_additions
Added HCPCS codes G2058, G2064 and G2065 to the policy (January 2020).
2019-05policy_clarification
Clarified that TCM services during a global surgical period cannot be billed by the same practitioner (May 2019).
2019-01-01implementation
Policy implementation (effective January 2019).
The policy history documents additions and removals of BHI and related care management codes over time. Notable entries: 4/2020 added codes 99484, 99492, 99493, 99494, 99487, 99489, 99490, 99491 for applicable regions; 3/2021 removed HCPCS code G2058 and added 99439 and G2214; 1/2022 added principal care/telephone and prolonged service codes 99424, 99425, 99426, 99427, 99437; and 6/2022 removed G2065 and G2064. The May 2026 update (policy effective date 2026-05-25) further recorded additions including 99497 and 99498 per the change log.
Policy Summary
PayerHighmark Pennsylvania
PolicyCare Management
Policy CodePolicy RP-043
Change TypeCodes addedformatting and definitional clarifications
Effective DateMay 25, 2026
Next Review Date
Key ActionSelect care management codes based on required time thresholds and document consent and comprehensive care plans.
SourceLink
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