Overview of CPT codes for Medsien related products

Medsien offers software and solutions for a suite of services – including CCM, PCM, RPM, RTM, TCM and AWVs.  Accurate coding is essential for proper reimbursement.

Below you will find the current CPT codes for each service and program we provide. These include any notable 2024 changes, clarifications or updates.

Chronic Care Management (CCM) CPT Codes

Chronic care management (CCM) services are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. The Centers for Medicare & Medicaid Services (CMS) recognizes that CCM services are critical components of primary care that promote better health and reduce overall health care costs.

The Basic CPT code for CCM, 99490, requires that patients must have two or more chronic conditions, as well as documented consent to enroll in the program AND receive at least 20 minutes of CCM services from clinical staff within a given month.  A personalized care plan, which shows an assessment of all patient factors and identifies gaps and barriers to be addressed, is also required. 99490 was amended to clarify use for only the first 20 minutes of CCM in a given month.

Practices should use CPT code 99439, chronic care management services, for each additional 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month. This code should be listed separately in addition to the initial code (99490) used for the primary procedure/CCM. This code allows providers to bill for each additional 20 minutes of time spent for basic CCM services in a given month, up to 2 times. For example, if CCM services were provided for at least 40 minutes with a patient in a given month that was not Complex, 99490 and 99439 would be billed together for that month.  A provider can still bill for up to 60 minutes of CCM care per patient per month in 20 minute installments – and would use 99490 plus 99439 plus 99439 again to bill codes for 60 minutes of CCM.

For Complex CCM patients, CMS offers CPT code 99487, which has a higher rate of reimbursement than the Basic CCM CPT code. To bill using this code requires moderate or high complexity in medical decision making AND acknowledgement by both patient & provider of an acute exacerbation (generally defined as a sudden worsening of a patient’s condition) that necessitates additional time and resources. Patients must receive at least 60 minutes of services from clinical staff within a given month to bill for this code. As with the basic CCM code, the Complex Chronic Care Management code also has an add-on CPT code to cover time spent beyond 60 minutes – CPT code 99489. This code allows for billing for each additional 30 minutes of time spent for Complex CCM services within a given month. For example, if 90 minutes of clinical services are provided to a patient in a given month that was Complex, they would bill 99487 and 99489 for that month.

CPT codes used to report CCM services:

• ‍CPT code 99490 – non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability. ‍
• CPT code 99439 – each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified healthcare professional (billed in conjunction with CPT code 99490)‍
• CPT code 99487 – complex CCM is a 60-minute timed service provided by clinical staff to substantially revise or establish a comprehensive care plan that involves moderate- to high-complexity medical decision making.‍
• CPT code 99489 – each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualified healthcare professional (report in conjunction with CPT code 99487; cannot be billed with CPT code 99490)‍
• CPT code 99491 – CCM services provided personally by a physician or other nurse practitioner for at least 30 minutes. This code is typically for higher risk patients. 99490 and 99491 cannot be billed in the same month.

For more information about CCM click here

Principal Care Management (PCM) CPT Codes

CMS reimburses for Principal Care Management (PCM) services provided to beneficiaries with a single high chronic condition to stabilize that condition following exacerbation or hospitalization. Unlike CCM, which requires a minimum of two conditions and the management of total patient care, PCM focuses on disease-specific care.  The qualifying condition for reporting PCM codes would be a patient with one serious chronic condition, typically expected to last at least three months and includes “establishing, implementing, revising or monitoring a care plan specific to that disease.  While CCM is furnished primarily by primary care providers, PCM typically is furnished by specialists or primary care providers.

Billing for PCM requires 30 minutes of care management services per month, as opposed to 20 minutes for CCM.  In 2022, CMS added add-on codes for each additional 30 minutes of PCM time as well. As part of this expansion, CMS also  renamed some of the previous CPT codes. PCM services furnished by clinical staff under general supervision are now billed using CPT code 99426 (previously G0265) for the initial 30 minutes, and 99427 for each additional 30 minutes.  Services furnished directly by a practitioner (physician, NPP) are now billed using 99424 (previously G0264) for the initial 30 minutes, and 99425 for each additional 30 minutes.

Practitioners billing for PCM must document in the patient’s record ongoing communication and care coordination between all practitioners providing care to the beneficiary. And providers cannot bill for interprofessional consultations or other care management services (excluding RPM) for the same beneficiary for the same time period as PCM. Otherwise, the same requirements apply to CCM and PCM.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) bill for CCM or PCM services performed by clinical staff under HSPCS G0511.  An RHC/FQHC can bill only one unit of G0511 per beneficiary per month, regardless of time spent on PCM for the patient.

CPT codes used to report PCM services:

• ‍CPT Code 99426 – Initial 30 minutes, principal care management clinic staff‍
• CPT Code 99427 – Subsequent 30 minutes, principal care management clinic staff (each additional)‍
• CPT Code 99424  – Initial 30 minutes, principal care management physician/NPP ‍
• CPT Code 99425 – Subsequent 30 minutes, principal care management physician/NPP (each additional)‍
• HCPCS Code G0511 – General care management for RHCs and FQHCs

For more information about PCM click here

Remote Patient Monitoring CPT Codes

In 2022, CMS expanded, CMS is expanding the types of remote services covered to include Remote Therapeutic Monitoring (RTM) in addition to Remote Physiologic Monitoring (RPM) services.

Remote physiologic monitoring (RPM) involves the collection and analysis of patient physiologic data that are used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition. The five primary Medicare RPM CPT codes are 99091, 99453, 99454, 99457, and 99458.  

The RTM codes expand the scope and reach of digital health technologies to reimburse monitoring of non-physiologic data and since 2023, their scope has expanded further to allow for general supervision as well. The codes are limited to the musculoskeletal system and respiratory system and are intended to be non-physiologic in nature with attention to therapy, adherence and response. The primary Medicare RTM codes are 98975, 98976, 98977, 98980, 98981. And new in 2024, also HSPCS G0511

Remote Physiologic Monitoring (RPM) CPT Codes

In 2019, CMS initially described RPM as services rendered to patients with chronic conditions, but confirmed in the 2021 Final Rule that going forward practitioners may furnish RPM services to remotely collect and analyze physiologic data from patients with acute conditions, as well as patients with chronic conditions.

Each process and component of RPM is billed under a separate CPT code.

• Service Initiation – billed under CPT 99453 – remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.
• Data Transmission – billed under CPT 99454 – remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; each 30 days.
• Data Analysis and Interpretation – billed under CPT 99091 – collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or electronically transmitted for the patient and/ or caregiver to the physician or other qualified healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.
• Treatment Management Services – billed under CPT 99457 – remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; (initial 20 minutes) and CPT 99458 (each additional 20 minutes).

In addition, CMS has provided some clarification on extra time requirements and coverage for these codes:

• Providers should use  CPT code 99457 for the initial 20 minutes of staff time, which can include extra time for interactive communication as well as for furnishing care management services (like reviewing numbers, planning calls, having discussions with providers, etc.).
• Providers should use CPT code 99458 for each additional 20 minutes of care (after the first additional 20 minutes which are billed to 99457), meaning there is no cap on the number of minutes that can be billed per patient, per month for RPM.  
• CMS clarified and confirmed that FDA clearance is not required as long as the device meets the FDA’s definition of a medical device. And devices must be reliable and valid, and collect and transmit data electronically (automatically) as patients/caregivers may not self-report or self-record for RPM.

CMS is also making several changes that should make it easier to bill Medicare for remote patient monitoring (RPM) of physiologic parameters:

• Permanently allowing consent to be obtained at the time RPM services are furnished,
• Allowing auxiliary personnel to furnish RPM services (as described by CPT codes 99453 and 99454) under the billing physician’s supervision,
• Clarifying that RPM services can be furnished to patients with acute conditions as well as those with chronic conditions,
• Clarifying that interactive communication (for the purposes of CPT codes 99457 and 99458) involves real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other data transmission.

For more information about RPM click here

Remote Therapeutic Monitoring (RTM) CPT Codes

In 2022, CMS introduced a new category of digital health services – Remote Therapeutic Monitoring (RTM) – and the associated billing and reimbursement codes to accompany these services. The new codes are intended to expand the scope and reach of digital health technologies to reimburse monitoring of non-physiologic data. The RTM family includes three practice expense (PE)-only codes and two codes that include professional work.

The intent for RTM is different in scope and data gathering methodology than RPM.  The codes are limited to the musculoskeletal system and respiratory system, and are intended to be non-physiologic in nature with more attention to therapy, adherence and response.

There are a few key differences between RTM and RPM coding.  First, the expansion beyond internal medicine providers and the addition of specialty areas, shows that providers that currently can’t bill for RPM (depending on specialty area) may be able to bill for RTM. The second major difference is the nature of the data collected – therapeutic for RTM and physiologic for RPM.  RTM can be used for non-physiologic medical devices like those used to support medical adherence (e.g. smart pill reminder systems) and medication symptom/adverse reaction applications.  Really any medical device that can collect data that is non-physiologic can be collected and billed under RTM.

Also, the clinical scope of what’s covered under RTM is fairly limited – clinical uses eligible for monitoring device reimbursement are only for respiratory condition data transmissions (CPT 98976) or musculoskeletal condition data transmissions (CPT 98977). Most stakeholders are optimistic that CMS will expand the list of clinical conditions in the future. However, CMS supported further expansion of RTM, by expanding the definition of these same codes to now allow for general supervision billing – allowing for broader use of this type of remote monitoring. Most stakeholders are optimistic that CMS will expand the list of clinical conditions  – or other aspects of RTM – in the future.

CPT codes used to report RTM:

• Service Initiation – CPT# 98975 – Remote therapeutic monitoring (e.g. respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment
• Data Transmission – CPT# 98976 – Remote therapeutic monitoring (e.g. respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g. daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days
• Data Analysis & Interpretation – CPT# 98977 – Remote therapeutic monitoring (e.g. respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g. daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days

Treatment Management Services

• CPT# 98980 – Remote therapeutic monitoring treatment, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes
• CPT#98981 – Remote therapeutic monitoring treatment, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes

Finally, CMS will allow self-reported/entered data for non-physiologic data RTM codes, but requires use of an FDA approved medical device, not a wellness device.  This is another significant difference from RPM code requirements, which require the device to digitally (automatically) record and upload patient physiologic data – and specifically do not allow patient self-recorded, reported or manually entered data.

It is expected that the coding, scope, range and specificity of RTM coverage and services will grow and change in the coming years as CMS further defines its policy.  

For more information about RTM click here

Transitional Care Management (TCM) CPT Codes

Transitional care management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g. skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

Two CPT codes are used to report TCM services:

• 99495, TCM: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit within 14 calendar days of discharge.
• 99496, TCM: Communication (direct contact, telephone, electronic) with patient and/or caregiver within two business days of discharge; medical decision making of high complexity during the service period; face-to-face visit within 7 calendar days of discharge.

Some important requirements and specifics for proper completion of TCM services are:

• Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
• Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
• Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
• Obtain and review discharge information.
• Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments.
• Educate the beneficiary, family member, caregiver, and/or guardian.
• Establish or reestablish referrals with community providers and services, if necessary.
• Assist in scheduling follow-up visits with providers and services, if necessary.

TCM billing has some other detailed requirements as well. The first face-to-face visit is part of the TCM and not reported separately; additional evaluation and management services after the first face-to-face visit may be reported. Only one individual may report TCM services and only once per patient within 30 days of discharge.

The 30-day period for the TCM service begins on the day of discharge and continues for the next 29 days. The reported date of service should be the date of the required face-to-face visit. You may submit the claim once the face-to-face visit has occurred, and do not need to hold the claim until the end of the service period.  If a patient dies prior to the 30 days following their in-patient discharge, you may not bill for TCM, but you may bill for any face-to-face visits that did occur under the appropriate evaluation and management code. Other reasonable and necessary Medicare services may be reported during the 30-day period, with the exception of those services that cannot be reported according to CPT guidance and Medicare HCPCS codes G0181 and G0182.

Qualifying patients can be discharged from any of the following facilities:  

• Inpatient acute care hospital
• Long -term acute care hospital
• Skilled nursing facility/nursing facility
• Inpatient rehabilitation facility
• Hospital observation status or partial hospitalization

Health care professionals approved to provide and bill TCM include, Physician (any specialty), Clinical nurse specialist (CNS), Nurse practitioner (NP), Physician assistant (PA) or Certified nurse midwife.

Back in 2021, CMS made changes to allow both CCM time and TCM time to be billed in the same month for the same patient when reasonable and necessary.

For more information about TCM click here

Medicare Annual Wellness Visit (AWV) CPT Codes

The Medicare Annual Wellness Visit (AWV) is a Medicare specific annual health status check where patients have vitals and health status indicators assessed, to provide an opportunity for earlier support and intervention for chronic conditions or concerns. An AWV is not the same type of exam as an annual physical – and they are each assessed and billed differently.  An AWV is only for Medicare patients and a broad range of health care providers can do the visit – broader than can for the physical.

An Annual Wellness Visit is different from the annual physical in several ways. Unlike an annual physical, the AWV does not require a physical exam, but rather is a preventive service that assesses aspects of a Medicare patient’s self-reported health status, family history and medical history to identify risk factors. This is done through a health risk assessment (HRA), which is a questionnaire that the patient can complete on their own. Yearly physicals include an examination by the primary care provider (doctors, nurse practitioners, or physicians assistants) of the patient’s body and current health. They also can be completed for any patient, regardless of age. In contrast, AWVs can be performed by a wider variety of medical professionals, extending to clinical nurse specialists and nurse practitioners.

The order and coverage of AWV billing is very important for proper coding and reimbursement. Medicare started covering AWVs back in January 2011. This benefit was included in the Affordable Care Act of 2010. Medicare has three billing codes used for these visits – G0402, for the Welcome to Medicare AWV, and G0438 for the initial AWV and G0439 for subsequent AWV visits.

These are used at the following times:

Welcome to Medicare AWV G0402

During the first year of Medicare enrollment patients should have their Welcome to Medicare Annual Wellness Visit.  Welcome to Medicare AWV  G0402  – This means their first ever AWV (as a new Medicare beneficiary) during the first year the patient is enrolled in Medicare.

Initial AWV G0438

If you’re not in your first calendar year of Medicare coverage, and you have never had an AWV, you have the Initial AWV G0438 – The initial AWV is for patients enrolled in Medicare for more than one year, but who are new to the AWV and have not had one before. If you had a Welcome to Medicare Visit during the previous calendar year, you should have your initial AWV one full calendar year after the Welcome to Medicare AWV appointment.

Subsequent AWV G0439

After you have had your Welcome and/or Initial AWVs, for all following years your Annual Wellness Visit  is called the Subsequent AWV.  Subsequent AWV G0439 – A patient is eligible for the Subsequent AWV one calendar year after the initial AWV (G0438). If a patient having a Subsequent AWV, has already had their initial AWV (and sometimes, had the Welcome to Medicare AWV), it should be one calendar year since that last AWV appointment, then they are eligible to have Subsequent AWV each year thereafter.  

For more information about AWV click here

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