Care Management

Chronic Care Management

Table of Contents

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Billing Codes

  • 99490: Provide at least 20 minutes of clinical staff time directed by a physician or another qualified healthcare professional
    • 99439: Each additional 20 minutes
  • 99491: Provided personally by a physician or other qualified health care professional, at least 30 minutes
    • Note: Time only the billing practitioner spends
    • 99437: Each additional 30 minutes (add-on code for CPT code 99491)
  • 99487: Complex chronic care management services- 60 minutes of clinical staff time directed by a physician or other qualified health care professional
    • 99489: Each additional 30 minutes
  • G0506: Comprehensive assessment
    • Note: Billing practitioners can bill G0506 only once, as part of initiating visit

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Chronic Pain Management and Treatment Codes

  • G3002: Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate.
    • Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month.
    • Note: When using G3002, 30 minutes must be met or exceeded.
  • G3003: Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month.    
    • List separately in addition to code for G3002
    • When using G3003, 15 minutes must be met or exceeded

Telehealth applies to both codes.

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Billing and Documentation

  • CCM requires the use of certified electronic health information technology
  • Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow up after discharges from hospitals, skilled nursing facilities or other health care facilities
  • Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers
  • Only one practitioner can furnish and be paid for these services during a calendar month
  • Inform the patient of the availability of CCM services
  • Copy of the plan of care must be given to the patient and/or caregiver
  • Beneficiary’s right to stop the CCM services at any time. (effective at the end of the calendar month)
  • Document in the patient’s medical record that the required information was explained and whether the patient accepted or declined the services.
  • Initiation during an AWV, IPPE or face-to-face E/M visit (Level four or five visit not required), for new patients or patients not seen within one year prior to the commencement of CCM services
  • Structured recording of demographics, problems, medications and medication allergies using certified EHR technology: A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination, and ongoing clinical care
  • Provide 24/7 access to physicians or other qualified health care professionals or clinical staff, including providing patients/caregivers with means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week

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Care management for chronic conditions including:

  • Systematic assessment of the patient’s medical, functional and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services
  • Medication reconciliation with review of adherence and potential interactions and oversight of patient self-management of medications

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Revised 7/7/2025