Pat Stricker, RN, MEd

Senior Vice President

Chronic Care Management, Advanced Care Planning, Transitional Care Management, and Behavioral Health Integration

The incidence of chronic conditions in the U.S. is astounding:

  • One-half of all adult Americans (117 million) have a chronic condition
  • One in four Americans (25%) have 2 or more chronic conditions
  • Two of three Medicare beneficiaries (66%) have 2 or more chronic conditions
  • One in three Medicare beneficiaries (33%) have 4 or more chronic conditions
  • 7 of the top 10 causes of death in 2014 were due to chronic diseases
  • 84% of our national health care spending is for chronic conditions; 99% of Medicare spending is for chronic conditions
  • Medicare payments for chronic care totaled $597 billion in 2014

The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better care, improved health outcomes, higher patient satisfaction, and smarter spending.  CCM is person-centered and requires extensive care coordination among practitioners and providers and centralized management of patient needs.  Therefore CMS has been enlarging the number and types of CCM services that are included in the Medicare Physicians Fee Schedule (MPFS).

In December 2014 I wrote an article in the CMSA newsletter entitled “New Medicare Payment Policy Opens the Door for Case Managers” describing the new Chronic Care Management billing codes and pointing out how encouraging it was to see CMS acknowledge the need to pay for care management services. It was truly a validation of the importance and value that care management brings to patients and the entire health care industry. At the time, CMS had plans to enlarge the CCM program, so I thought it might be time to take a look at the progress that has been made in the past 2 ½ years.


Chronic Care Management Services

On January 1, 2015 CMS began paying for CCM services under the Medicare Physician Fee Schedule (MPFS) that established payment levels and policy changes for Medicare Part B services. It allowed physicians, advanced practice nurses, physician assistants, clinical nurse specialists and certified nurse midwives to bill a monthly fee for non-face-to-face care coordination and CCM provided to Medicare beneficiaries with multiple chronic condition. Previously, CMS primarily only paid for face-to-face care management visits.

CCM services focus on a continuous relationship with a designated member of the care team; patient support for chronic diseases to achieve health goals; structured documentation; ongoing development and revision of care plans; communication with other providers; medication management; 24/7 patient access to care and health information; receipt of preventive care; patient and caregiver engagement; and timely sharing and use of health information, including electronic data.  (A detailed list of 2017 requirements can be found in the Chronic Care Management Services 2017 Fact Sheet).

The original CCM billing code (CPT code 99490) was for services for patients who had two or more chronic conditions expected to last at least 12 month or until the death of the patient. It required a comprehensive care plan be established, implemented, revised, or monitored and it paid for at least 20 minutes of clinical staff time each month for the billing practitioner or care team members under his/her direction. The ability to bill for team members made it possible for physicians to provide more CCM services, thereby making more CCM services available to patients.

The program has been a big success and in January 2017 CMS adopted 3 additional billing codes that allows more billable time for the Initiating Visit and Complex CCM. HCPCS Code G0506 – Add-On ($64) is used for additional time spent on assessment or care planning for the CCM Initiating Visit.  While Complex CCM shares the same requirements as CCM, the fees are higher for Complex CCM to compensate for moderate or high complexity decision-making, the increased time required to manage these patients (30-60 minutes/month), and the extended care planning needed.  CPT 99487 – Complex CCM ($94) is used for 60 minutes of staff time for complex CCM and CPT 99489 – Complex CCM Add On ($47) is used for each additional 30 minutes of Complex CCM time needed each month.

Other 2017 changes for CCM Services included:

  • Additional payment for complex patients
  • Verbal patient consent rather than written
  • Reduced technology requirements: retained requirement for EHR, but no longer requires electronic exchange; care plan and transition documents just need to be exchanged in a “timely” manner; Faxing is an acceptable mode of transmission.
  • Simplified documentation
  • Initiating visit only needs to be done for new patients or those who have not been seen within a year (rather than all patients)

NOTE: See the following documents for more specific details and requirements for CCM:

When the CCM program was implemented in 2015, CMS planned to add other care coordination, wellness, behavioral health, and care transition programs in the future. The following is a summary of the progress made in those areas.

Advance Care Planning

In January 2016 CMS began paying for voluntary Advance Care Planning (ACP) that enables Medicare beneficiaries to make important decisions that give them control over the type of care they receive and when they receive it. Voluntary ACP includes discussion about the care patients want to receive if they become unable to speak for themselves, including the explanation and forms needed for advance directives.

Billing codes include the time it takes physicians and other qualified health care professionals to explain and discuss advance directives and help patients complete the forms.  CPT Code 99497 is used for the first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate, and CPT Code 99498 is used for each additional 30 minutes.

NOTE: See the following documents for more specific details and requirements about Advance Care Planning:


Transitional Care Management

Transitional Care Management (TCM) services actually began in January 2013 to help provide care management services to patients for 30 days following discharge from a hospital, partial hospitalization, skilled nursing facility, community mental health center, or outpatient observation stay.

The TCM services that must be provided beginning on the date the patient is discharged from an inpatient setting include:

  • An Interactive Contact – must be made with the patient or caregiver within 2 business days via phone, email, or face-to-face to address the patient’s status and needs, as well as to schedule follow-up care.  Attempts should continue until they are successful. TCM cannot be billed if the face-to-face visit is not finished within the required timeframe.
  • Certain Non-Face-to-Face Services – The following should be done by the physician, NPP, or other qualified team members under their direct supervision:
    • Obtain and review discharge information (discharge summary or continuity of care documents)
    • Review need for or follow-up on pending diagnostic tests and treatments
    • Interact with health care professionals who will assume or reassume care of the patient
    • Provide education to the patient, family, guardian, and/or caregiver
    • Establish or re-establish referrals and arrange for needed community resources
    • Assist in scheduling required follow-up with community providers and services
    • Communicate with agencies and community services the patient uses
    • Provide education to the patient, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living
    • Assess and support treatment regimen adherence and medication management Identify available community and health resources
    • Assist the patient and/or family in accessing needed care and services
  • A Face-to-Face Visit – must provide one face-to-face visit within certain timeframes, depending on whether the medical decision complexity is rated as moderate or high. To qualify for a moderate or high complexity decision, 2 of the 3 following criteria must be met:
    • The number of diagnoses and/or management options must be multiple (moderate) or extensive (high)
    • The amount and/or complexity of data to be reviewed must be moderate or extensive (high)
    • The risk for significant complications, morbidity, and/or mortality must be moderate or high

NOTE: This rating is detailed in a Table on page 6 of the Transitional Care Management Services document.

The billing code for a moderate medical decision complexity case is CPT Code 99495 that requires a face-to-face visit within 14 days of discharge. CPT Code 99496 is used for a high medical decision complexity case that requires a face-to-face visit within 7 days of discharge.

Telehealth Service codes can be used for the face-to-face visits to satisfy the above billing codes. CMS will pay for a limited number of Part B services furnished by a physician or practitioner via a telecommunications system instead of an in-person encounter.

  • Medication Reconciliation and Management – Medication reconciliation and management must be provided no later than the date you provide the face-to-face visit.

NOTE: See the following documents for more specific details and requirements about Transitional Care Management:


Behavioral Health Integration (BHI)

Integrating behavioral health care with primary care is now widely considered to be an effective strategy for improving outcomes for the millions of Americans with mental or behavioral health conditions. Beginning January 1, 2017, Medicare began making separate payments to physicians and non-physician practitioners who provide the Psychiatric Collaborative Care Model (CoCM) to patients, a model that has shown improved outcomes in multiple studies. CMS also pays for General BHI services that use BHI models of care other than CoCM and for those that do not involve a psychiatric consultant or a designated behavioral health care manager.


Psychiatric Collaborative Care Services (CoCM)

The Behavioral Health Integration Services Fact Sheet describes CoCM as a BH model that enhances “usual” primary care with the addition of two key services:

  • Care management support for patients receiving behavioral health treatment
  • Regular psychiatric inter-specialty consultation to the primary care team, particularly regarding patients whose conditions are not improving.

CoCM Service Components include:

  • Initial assessment with an initiating visit and administration of validated rating scale(s)
  • Joint care planning by the primary care team and patient, with care plan revisions for patients whose condition is not improving
  • Pharmacotherapy, psychotherapy, and/or other indicated treatments
  • Proactive, systematic follow-up using validated rating scales and a registry
    • Assess treatment adherence, tolerability, and clinical response using validated rating scales
    • Provide brief evidence-based psychosocial interventions, e.g. behavioral activation or motivational interviewing
    • 70 minutes of behavioral health care manager time the first month; 60 minutes in subsequent months; and 30 additional minutes in any month
  • Regular case load review with psychiatric consultant
    • At least weekly reviews of the patient’s treatment plan and status (treatment is maintained or adjusted)
    • Referrals are made to BH specialty care, as needed.


General Behavioral Health Integration Services

This program uses BHI models of care other than CoCM and those that do not involve a psychiatric consultant or a designated behavioral health care manager.  They include basic “core” service elements.

BHI Services Components include basic core service elements:

  • Initial Assessment  and care planning as described above in the CoCM program
  • Systematic assessment and monitoring, using applicable validated clinical rating scales
  • Facilitation and coordination of behavioral health treatment
  • Continuous relationship with a designated member of the care team

The following billing codes are used for:

  • Psychiatric Collaborative Care Model (CoCM).:
    • HCPCS Code G0502                  First month                              70 minutes
    • HCPCS Code G0503                  Subsequent months            60 minutes/month
    • HCPCS Code G0504                 Add-On (any month)           Additional 30 min/month
  • Behavioral Health Integration Models (BHI):
    • HCPCS Code G0507 – used to bill for all services provided in a non-CoCM model of care (General BHI program); at least 20 minutes/month


It is encouraging to see that Medicare Care Management Services continue to prosper and grow. Knowing that these areas are now billable is a great achievement compared to the past when only face-to-face encounters were billable, and only if they were performed by a physician. However, it is disappointing to know that even though professional case managers are the ones actually providing most of the care management services, we still are not considered providers and therefore cannot independently bill for these services.

I am mindful of a comment Cheri Lattimer, our previous CMSA executive director, made in a CMSA Today article at the time the CCM codes were initially released – “It is extremely important that as case managers, we begin to strategize how qualified, professional case managers can be recognized as providers of chronic care management and case management services and work toward achieving Medicare billing status.”  We have made great strides, but we need to continue to validate the valuable services that professional case managers provide, so that one day we will be able to reach our goal of billing independently for our services.