Series Part II: Complex Chronic Care Management Services

Complex chronic conditions are defined as any medical condition that can be reasonably expected to last at least 12 months (up to death), and involve either several different organ systems, or one organ system severely enough to require specialty care and the probability of a period of hospitalization at some point.

Examples of Complex Chronic Care Conditions:

• Advanced Heart Failure
• Congenital or Genetic
• End-Stage Renal Disease
• Malignancy
• Neurological Disorders
• Transplant

The complexity of chronic conditions may be identified by algorithms that recognize multiple illnesses, multiple medication use, inability to perform activities of daily living, requirement for a caregiver and/or repeat admissions or emergency department visits.

Typical adult CCCM patients are treated with three or more prescription medications and may be receiving other types of therapeutic interventions.

Pediatric CCCM patients receive three or more therapeutic interventions. This may be medications, respiratory therapy, nutritional support, etc.

Complex Chronic Care Management patients demonstrate 1 or more:

• Need for coordination of a number of specialties and services
• Inability to perform activities of daily living and/or cognitive impairment resulting in poor adherence to the treatment plan without substantial assistance from a caregiver
• Psychiatric and other medical comorbidities (e.g., dementia, COPD, substance abuse, and diabetes)
•  Social support requirements or difficulty with access to care

The code description for CCCM is similar to chronic care management, as outlined in article one of this series. CPT code selection for CCCM is based on meeting the elements required to report the service and requiring Moderate or High medical decision making.

CPT Codes

(CCCM) Complex Chronic Care Management Services

• 99487: Complex Chronic Care Management services; first 60 minutes of clinical staff time directed by a physician or OQHP, per calendar month (Novitas $136.84)
• +99489: …; Each additional 30 minutes of staff clinical staff time (Novitas $73.76)

Some time-based services have the benefit of the “past midpoint” rule. Not so for CCCM services. Complex Chronic care management services must meet the minimum time thresholds in order to be reported. If less than the stated time is met, do not report the service.

However, per CPT coding tip (CPT pg. 51), if the treating physician or OQHP personally performs ANY of the care management services and those activities are not used to meet the criteria for a separately reportable code (99424, 99491), then their time may be counted towards the required clinical staff time to meet elements of 99426, 99487, 99490, as applicable.

Patients must give consent to receive CCCM services. This can be given in written or verbal form and documented in the medical record.

This documentation in the medical record must include:

1. The patient’s consent to participate in CCCM,
2. That the patient was informed that she/he can stop receiving CCCM services at any time, and
3. That only one health care professional or hospital can provide CCCM in a calendar month.

Information about applicable cost sharing should be included as well.

For more in-depth information, we have included a plethora of resource links below. Stay tuned for the next article in this series.

Series Part III:  Principal Care Management 

Resources

CDI (internal link) Complex Chronic Care Management

Provider specialty: Care management services

Novitas TPE CCM Slide deck

CMS – Chronic Care Management MLN Booklet

Chronic Conditions Data Warehouse

Children’s Hospital Association – CCCM Article

Pediatric CCCM System version 3