Reporting CCM and TCM Codes with E/M Codes

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Jun 1st, 2022

When reporting CCM or TCM codes, you will only get reimbursed for what is allowed.  The E/M office visits can be coded in addition but are not interchangeable with CCM codes. You can bill an E/M visit during the time a patient is under Care Management, however, you can’t count time spent with the patient toward the CCM service if it is counted toward E/M.  The time cannot be counted twice.

CCM and office visits are not interchangeable, see the following rationale:  Office and other outpatient E/M services, such as 99202-99215, require different elements of medical decision making than CCM codes.  During the office visit, a patient is seen for a diagnostic visit, reviewing notes, and tests while evaluating the risk of the patient. Look at the required elements with the following E/M code types.

Required elements for 99204 – office visit: 

• Three major criteria (history, physical exam, and medical decision-making) must be met.
• A review of systems must include at least 10 systems
• History - Past, family, and social history must cover all three areas.

Care management services are just that, you are managing the care of an illness.  The required elements are listed in the AMA code description as follows:

“Required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death.  The condition requires development, monitoring, or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities, ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. ”

Access to Care & Care Continuity is an important part of Chronic Care Management (CCM), CCM providers are expected to provide the following: 

• Provide 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified practitioners or clinical staff, including providing patients or caregivers with a way to contact health care practitioners in the practice to discuss urgent needs no matter the time of day or day of the week.
• Provide continuity of care with a designated practitioner or member of the care team with whom the patient can get successive routine appointments.
• Provide patients and caregivers enhanced opportunities to communicate with their practitioners about their care by phone and through secure messaging, secure web, or other asynchronous non-face-to-face consultation methods (like email or secure electronic patient portal).

NOTE: “Beginning CY 2022, RHCs and FQHCs can bill CCM and TCM services for the same patient during the same time period”

Please refer to MLN -Chronic Care Management Services for more information. 
https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf