Complex vs. Non-Complex CCM: What's the Difference?

A Quick Overview of Chronic Care Management

Chronic Care Management aims to provide coverage to Medicare beneficiaries for non-face-to-face interactions that are essential for managing multiple chronic conditions. CCM services include a personalized care plan, 24/7 access to healthcare advice, referrals to outside providers as needed, medication management, and an ongoing review of the patient’s health status.

What is the Difference Between Complex and Non-Complex CCM?

Complex and non-complex Chronic Care Management (CCM) describe two billing tiers. The difference comes down to four things: How much clinical staff time was spent, what level of medical decision-making the billing practitioner used, how much care plan work was involved, and which CPT codes apply.

(It’s important to note that providers cannot report both types for the same patient in a single calendar month.)

The Importance of Medical Decision-Making

Deciding whether to bill for complex or non-complex CCM will depend on which of the following four levels of Medical Decision-Making (MDM) services fall under: Straightforward, low, moderate, or high. MDM is determined by the provider who takes into consideration the diagnoses, evaluation of the status of the condition, risk of complications, and the amount and/or complexity of data to be reviewed.

Which CPT Codes Apply to Non-Complex CCM?

Non-complex CCM services involve a straightforward or low level of MDM and are defined by the following four CPT billing codes:

CPT 99490 includes the first 20 minutes of non-face-to-face clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.

CPT 99439 serves to bill each additional 20 minutes beyond the initial 20 minutes included in CPT 99490, but not enough to be classified as complex CCM.

CPT 99491 includes the first 30 minutes of either face-to-face or non-face-to-face time between patient and provider.

CPT 99437 serves to bill each additional 30 minutes beyond the initial 30 minutes included in CPT 99491.

Which CPT Codes Apply to Complex CCM?

Complex CCM shares common service components with non-complex CCM, but the former includes more clinical staff service time, a moderate or high level of MDM, and more intense care planning.

The billing codes for complex CCM are as follows:

CPT 99487 includes the first 60 minutes of clinical staff time per calendar month, reserved for complex MDM that involves creating or revising a care plan.

CPT 99489 serves to bill each additional 30 minutes beyond the initial 60 minutes included in CPT 99487.

Complex CCM Patients Typically Exhibit the Following:

• The need for coordination of multiple specialties and services
• An inability to perform daily activities and/or cognitive impairment that hinders ability to adhere to the treatment plan without significant help from a caregiver
• Psychiatric and/or medical comorbidities that complicate the care plan
• Difficulty with access to care or the need for social support
• Three or more prescription medications, as well as other forms of therapeutic interventions