Non-Complex vs. Complex Chronic Care Management: What's the Difference?
- Clinii
- 6 days ago
- 3 min read
Chronic Care Management (CCM) is an important element of primary care for Medicare beneficiaries and healthcare providers alike, but it can be tricky to get the billing nuances exactly right. Today, we’ll explore the differences between the two CCM billing categories – non-complex and complex – so that your practice can steer clear of penalties and maximize opportunities for reimbursement.
A Quick Overview of Chronic Care Management
CCM aims to provide coverage to Medicare beneficiaries for any non-face-to-face interactions that are essential for managing multiple chronic conditions. CCM services typically 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.
An Intro to CCM Billing
The CPT codes used to bill CCM to the Centers for Medicare and Medicaid Services (CMS) are divided into two billing categories: Non-complex CCM and complex CCM.
(It’s important to note that providers cannot report both types for the same patient in a single calendar month.)
What Are the Primary Differences Between Non-Complex CCM and Complex CCM?
The amount of service time provided by clinical staff
The level of involvement, including Medical Decision-Making, by the billing practitioner
The scope of care planning involved
The Importance of Medical Decision-Making
Knowing which of the two categories to bill will depend on which of the following four levels of Medical Decision-Making (MDM) services fall under: Straightforward, low, moderate, or high. This is determined by the provider and factors in diagnoses, evaluation of the status of the condition, risk of complications, and the amount and/or complexity of data to be reviewed.
Non-Complex CCM Billing Codes
Non-complex CCM services involve a straightforward or low level of MDM and are defined by the following four CPT billing codes:
Includes at least 20 minutes of non-face-to-face clinical staff time, directed by a physician or other qualified healthcare professional, per calendar month.
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.
Includes at least 30 minutes of either face-to-face or non-face-to-face time between patient and provider.
Serves to bill each additional 30 minutes beyond the initial 30 minutes included in CPT 99491.
Complex CCM Billing Codes
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:
Includes at least 60 minutes of clinical staff time per calendar month, reserved for complex MDM that involves creating or revising a care plan.
Serves to bill each additional 30 minutes beyond the initial 60 minutes included in CPT 99487.
Complex CCM Patients Typically Exhibit the Following Attributes:
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
Know the Difference!
The differences between non-complex and complex CCM may seem minor, but it’s important to have a solid understanding of them and bill correctly so that your practice can avoid penalties that result in lost revenue. Leveraging an advanced AI-powered Chronic Care Management platform can help care teams more accurately identify eligible patients, resulting in better health outcomes and higher revenue streams.
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