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Reimbursement for Care Coordination Services

To pay for care coordination services, many rural programs seek reimbursement opportunities. One reimbursement opportunity is to use Current Procedural Terminology (CPT) codes to bill insurers for care coordination services provided. Each insurer may respond to the codes differently. Rural programs should identify which codes are covered and by which insurers, how much money is offered, and how to properly use the codes.

There are several CPT codes for transitional care management (TCM), complex chronic care coordination, and chronic care management (CCM). CMS provides specific guidelines for using these codes for care coordination (see Resources to Learn More). Examples of these codes include:

  • CPT Code 99495 – Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)
  • CPT Code 99496 – Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)
  • CPT Code 99490 – Chronic care management for a patient with multiple chronic conditions (at least 20 minutes of time spent with patient per month)
  • CPT Code 99487 – Complex chronic care management for a patient with multiple chronic conditions (60 minutes of time spent with patient per month)
  • 99489 – Each additional 30 minutes of time spent per month with patient on complex chronic care management services

For additional information on billing codes and reimbursement strategies, see RHIhub's tool: Care Management Medicare Reimbursement Strategies for Rural Providers.

Resources to Learn More

Chronic Care Management Services
Document
A fact sheet that provides information on CPT codes for CCM services.
Organizations: Centers for Medicare & Medicaid Services
Date: 12/2016

Chronic Care Management (CCM) Services for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
Document
Describes the payment changes for CCM services related to care coordination.
Organizations: Centers for Medicare & Medicaid Services
Date: 11/2015

Frequently Asked Questions about Billing the Medicare Physician Fee Schedule for Transitional Care Management Services
Document
Provides answers to questions related to Medicare payments under the Physician Fee Schedule (PFS) for two CPT codes used for transitional care management services.
Organizations: Centers for Medicare & Medicaid Services
Date: 3/2016

Frequently Asked Questions about Physician Billing for Chronic Care Management Services
Document
Provides answers to questions related to Medicare payments for three CPT codes used for CCM.
Organizations: Centers for Medicare & Medicaid Services
Date: 1/2017

Medicare Proposes Substantial Improvements to Paying for Care Coordination and Planning, Primary Care, and Mental Health in Doctor Payment Rule
Document
Press release describing the proposed transformation to Medicare payments for care coordination.
Organizations: Centers for Medicare & Medicaid Services
Date: 7/2016

What Practices Need to Know about Transition Care Management Codes
Document
This article provides practical information on TCM services and billing as they related to CPT Codes.
Organization(s): American College of Physicians
Date: 12/2016