(Last Updated On: December 2, 2016)
Determining reimbursement rates for CPT 99490 (Chronic Care Management) should be a relatively straightforward process. For traditional Medicare, simply view the current year’s Physician Fee Schedule (for ease of use view the rates on the “For Providers” section of our website). Unfortunately outside of traditional Medicare, CCM rates can be hard to pinpoint. The rates can differ widely by region and payer. Providers often get inconsistent responses from the same plan depending on who they speak to. Even though it has been nearly a year and half since CCM’s inception, many Medicare Advantage plans, Medicaid programs, and commercial payers have not yet fully baked 99490 into their standard operating procedures. Hence some representatives from the plan may not be aware of 99490 even if it is available. Below are some tips on how to find out if CCM / 99490 is reimbursed in your area by Medicare Advantage, Medicaid, and/or commercial payers.
Contact your biller
Staying on top of local reimbursement policies is one of the core functions of any medical billing agency. Whether it’s your own biller or simply one that is in your area, billers deal with claims from across many practices and many payers. If even one of their clients participates in a Chronic Care Management program, chances are they have billed 99490 at some point. They should have information on the reimbursement rates from these claims. If not, they still deal with payers on a day to day basis to handle denials and other claim submission issues. They can reach out to their payer contacts to get to the bottom of what the 99490 rates are in your area.
Reach out to local associations (e.g., MGMA, Primary Care Association)
Associations are another source of knowledge for 99490 reimbursement. Many times the association will have a provider education team that coaches providers on changes to healthcare policy, coding, etc. These teams also speak to a variety of practices; chances are one of these practices has launched a Chronic Care Management program and knows the rates for major insurance plans in your area. Often associations may have already launched a training module on CCM and have gathered all this information for you already!
Speak to the plan representative
Perhaps one of the easiest methods for finding out information on the plan is to send an email to or call the plan representative that your practice typically deals with. Unfortunately this particular method yields mixed results. If the representative is not very well educated about CCM, he/she may provide you with incorrect information (i.e., 99490 is not covered) as CCM is still relatively new. If you receive a “not covered” answer from the representative, it is advisable to use a few of the other methods outlined in this post to validate the response on 99490 coverage.
Call the plan’s 1-800 number
As long as you are okay dealing with long hold times, calling the 1-800 number from the plans website is an option. Unfortunately, this method has the same pitfalls as method 3. In fact, the chances that the call center agent knows about 99490 or CCM are slim. The agent will likely place you on a hold while asking his/her colleagues about CCM or 99490. Occasionally the agent will have access to reimbursement rates via a web portal or software platform and will be able to give you accurate 99490 reimbursement information. Again if you receive a “99490 is not covered” response from this method, try another method to validate the findings.
Perform a pre-estimate
Some payers will give providers access to an IT platform that allows them to perform
“pre-estimates” to determine what reimbursement will be for particular procedures. Simply run a pre-estimate on 99490 and see what result you get!
Run a test claim
Similar to method 5, some plans allow you to run a “dummy” claim to see whether claims will be processed successfully or not. In fact, during the transition from ICD-9 to ICD-10 in 2015 there were over 15,000 test claims submitted to CMS (see https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2015-Jan-End-to-End-Testing.pdf). If the plan in question allows for test claims, this is perhaps the most surefire way to see whether Chronic Care Management is covered by your insurance plan. Run a dummy 99490 claim and see what the resulting reimbursement is!