CPT 99439 Description, Billing Rules, and Use Cases
CPT 99439 is a time-based add-on code for extended Chronic Care Management (CCM) services beyond the first 20 minutes of clinical staff time.
On this page, you’ll find billing thresholds, documentation guidance, compliance considerations, and real-world examples to help your team use CPT 99439 correctly—and maximize care revenue.
What is CPT Code 99439?
CPT 99439 is a CPT code used to describe additional non-face-to-face CCM services when total clinical staff time exceeds 20 minutes beyond what’s reported with CPT 99490. It is reported in addition to CPT 99490 when total clinical staff time reaches 40 minutes or more in a calendar month.
This code supports extended patient care for individuals with two or more chronic conditions expected to last at least 12 months or until death. Services must be provided under the general supervision of a physician or other qualified healthcare professional, and up to two units of CPT 99439 may be billed per month.
CPT 99439 Time Thresholds and Code Combinations
Use CPT 99439 in any calendar month where your clinical staff spend more than 20 minutes delivering non-face-to-face CCM services and meet the criteria for billing CPT 99490. Each additional 20-minute increment beyond the first qualifies for one unit of CPT 99439 — up to two units per month.
This code is appropriate for practices that provide consistent, high-touch care to patients with complex chronic conditions, especially when monthly management needs exceed baseline thresholds.
When to Use CPT 99439: Common Scenarios and Use Cases
CPT 99439 is an add-on code used for each additional 20 minutes of Chronic Care Management (CCM) services furnished by clinical staff under the direction of a physician or other qualified healthcare professional (QHP) in a given calendar month. This code must be billed in conjunction with CPT 99490 when the total time exceeds the initial 20 minutes.
Below are common use cases for when to bill CPT 99439:
Extended Care Coordination for Heart Failure
Clinical staff spends time:
- Monitoring daily weight logs and fluid status updates
- Communicating medication changes from cardiology and primary care
- Educating the patient on lifestyle changes and follow-up care
Total qualifying time: 45 minutes
Billing: 99490 + 99439
Complex Multi-Specialist Case for COPD and Diabetes
Nursing staff delivers:
- Reviewing pulmonology and endocrinology recommendations
- Coordinating overlapping medication changes and refill requests
- Updating care plan with supervising physician input
Total qualifying time: 60 minutes
Billing: 99490 + 99439 ×2
Assisted Living Resident With Escalating Needs
Clinical staff supports:
- Collecting vitals and symptoms from facility staff
- Coordinating referrals to physical therapy and neurology
- Documenting frequent updates to the care plan for the provider
Total qualifying time: 50 minutes
Billing: 99490 + 99439
CPT 99439 Billing Requirements and Eligibility
To bill CPT 99439 compliantly, your team must report it in conjunction with CPT 99490 when clinical staff time exceeds 20 minutes. Each additional 20-minute increment is one unit of 99439. A maximum of two units may be billed in a calendar month.
This code is used to capture time beyond the initial 20 minutes of non-face-to-face CCM services and must be:
- Directed by a physician or qualified healthcare provider
- Performed by clinical staff under general supervision
- Documented with detailed time logs and activity types
CPT 99439 cannot be billed alone and should not be combined with services that duplicate or overlap CCM time tracking. Proper patient eligibility and care plan documentation are required for reimbursement.
Patient Eligibility Criteria
- The patient must have two or more chronic conditions that:
- Are expected to last at least 12 months
- Place the patient at significant risk of functional decline, acute exacerbation, or hospitalization
- A comprehensive care plan must be:
- Established, implemented, revised, or monitored during the billing period
- Documented in the patient’s medical record and accessible to the care team
Provider Requirements
PT 99439 services must be delivered by clinical staff under the general supervision of a physician or other qualified healthcare professional. These services must be medically necessary, clearly documented, and integrated into the patient’s care plan.
The supervising provider is responsible for directing the care activities and ensuring that all time billed under CPT 99439 contributes meaningfully to chronic care coordination. Providers must also ensure appropriate documentation protocols are followed for audit-readiness and compliance.
Service Requirements
To qualify for billing CPT 99439, clinical staff must provide non-face-to-face services that contribute to the patient’s care plan. These services may include:
- Coordinating care between providers or facilities
- Communicating with the patient, caregivers, or family
- Reviewing test results or specialist reports
- Updating or modifying the care plan
- Managing medications and adherence
- Documenting time spent on chronic care tasks
All services must be provided under general supervision, align with the care plan, and be clearly documented in the patient’s medical record.
CPT 99491 Billing Documentation Checklist
- CPT 99490 must also be billed on the same claim
- A maximum of two units of 99439 may be reported per calendar month
- Time spent must be distinct, non-duplicative, and clearly documented
- Services must be delivered by clinical staff under general supervision
- Documentation should include:
- Total time spent
- Type of services provided
- Dates and names of care team members involved
- Avoid overlap with time-based codes like 99491, 99487, or 99358
Common CPT 99439 Billing Mistakes (and How to Avoid Them)
❌ Billing 99439 without 99490
This add-on code is invalid when reported on its own. Avoid it by always pairing CPT 99439 with a primary 99490 claim.
❌ Reporting too many units
Only two units of 99439 can be billed per patient, per calendar month. Avoid it by capping billing at two units and documenting distinct time blocks.
❌ Double-counting time
Time used for E/M visits, 99491, or other codes may not overlap. Avoid it by maintaining separate, non-duplicative time logs for each service.
❌ Missing care plan documentation
Claims may be denied if services are not tied to an active plan. Avoid it by updating and referencing the patient’s care plan in documentation.
❌ Incorrect provider attribution
Time must reflect services performed by clinical staff, not the billing provider. Avoid it by ensuring time logs clearly attribute services to qualified clinical staff.
