CPT codes are numbers assigned to services provided by a provider, including diagnostic, medical, and surgical services. An insurer will use these codes to determine the amount of reimbursement that a qualified practitioner will receive from an insurer for that service. Code 99490 is an obscure billing code used when some hospitals enroll patients in chronic care management or CCM plans. These plans are used to track care and, hopefully, keep people out of the hospital.


What Services are Required?

The code 99490 is used to code services provided to reduce unnecessary hospital visits. Some examples of the services that may be required are:

  • Annual clinical assessments of the patient in an office setting
  • Biennial clinical assessments in a community setting
  • Follow-up care for chronic conditions in the community
  • Patient education activities
  • Support groups


Who Qualifies for Code 99490?

The code 99490 is only for patients enrolled in a chronic care management plan, otherwise known as a CCM plan. The patient must have at least two chronic conditions that require regular medical treatment. These conditions are expected to last at least 12 months, like high blood pressure, diabetes, arthritis, and cancer. If the patient doesn’t receive regular treatment, it could be life-threatening.

To be eligible for the code 99490, a patient must fill out an application and provide information about their condition. Patients enrolled in other types of health care often do not qualify for the Code 99490 but can instead choose another billing code for their services.

What is a Comprehensive Care Plan?

A comprehensive care plan is a log of past medical history and an action plan for current medical conditions. It ensures that all physical care providers and hospitals have access to the same information.

The format of care plans is not explicitly dictated but should include the following information:

  • Service summary with notes from each month of service by a care coordinator
  • Contact information for the patient’s entire care team
  • Physical examination and laboratory tests performed
  • List of all referrals sent, if applicable
  • Medication list, including dose and schedule
  • Recent symptoms
  • Allergies
  • Health goals


How Does Monthly Service Work for Code 99490?

When a patient is listed in a CCM plan, the provider sends out reminders for all services to be performed. It can be done by phone, email, or fax. If a patient does not have access to these modes of communication or if they do not return the reminder, the provider sends another reminder. Once connected, the patient receives a comprehensive care plan sent to all providers.

Each month, a care coordinator will review the patient’s records in the EMR, updating all of the necessary fields. The coordinator will also collect data from all providers in the patient’s care team, creating a complete record.


How Much Does Medicare Reimburse?

The amount of reimbursement a provider can receive depends on the provider’s location. As of 2021, the average refund for non-facility chronic care management services was $42.21.


Can A Third Party Deliver Services on Behalf of the Practice?

A third party can bill on behalf of a patient. The EHR can transfer requested services to another provider. These providers may not provide care coordination services and may instead only offer treatment recommendations.

Furthermore, if the patient is discharged and signs an agreement with another provider, the original provider cannot be billed by that other provider on their behalf. This agreement is executed through a mutual release form between the patient and the hospital or physician’s office where they are treated.



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