The care management billing questions practices ask most.

No. CMS gives examples only: Alzheimer's and related dementia, arthritis, asthma, atrial fibrillation, autism spectrum disorders, cancer, cardiovascular disease, COPD, depression, diabetes, glaucoma, HIV/AIDS, hypertension and substance use disorders. CMS also suggests using CPT screening criteria such as number of illnesses, number of medications, or repeat admissions and ED visits (CMS CCM booklet).

Yes. CMS's CCM FAQ lists 99212–99215 as qualifying, and says a level 4 or 5 visit is not required. The visit must include a discussion of CCM, documented in the note.

CMS's FAQs name only the established-patient codes 99212–99215, but they also say a new patient must have an initiating visit, which by definition will be a new-patient code. Industry training treats 99202–99205 as qualifying (CAPC CCM training slides). Open question: confirm with your MAC; until then, document the CCM discussion explicitly in the 99203 note.

Yes for CCM and PCM. For APCM, only if the practitioner who will bill APCM performs the AWV.

Codes without a face-to-face visit by the billing practitioner, and services not separately payable by Medicare. A 99211 nurse visit is outside the 99212–99215 range CMS names.

No. The visit and consent are separate requirements; the visit is a convenient time to get consent.

CMS's CCM FAQ says yes when that E/M is allowed by telehealth under current rules. Check the current telehealth list before relying on it.

If the billing practitioner personally does extensive assessment and care planning beyond the usual visit work, bill G0506 once, as part of the initiating visit.

Generally yes, if it meets each program's own requirements and the note documents each one. No CMS source reviewed addresses this directly, and none prohibits it. The visit itself is billed once (E/M, AWV or TCM).

• Qualifying for each program. A 99213 or 99214 qualifies for CCM, PCM, BHI, APCM, PIN and CHI. An AWV qualifies for APCM, PIN and CHI only if the practitioner who will bill them performs it.
• Each program addressed in the note. CCM and APCM: the program was discussed. PIN: the serious, high-risk condition was addressed. CHI: the social needs and how they limit treatment were identified. BHI: the behavioral health condition and plan.
• Same billing practitioner. Each program is billed by the practitioner who furnished the initiating visit; a visit by one practitioner can't initiate a program billed under another.
• Separate consent. One visit can launch several programs, but each needs its own documented consent with its own required elements (Section 4).

Auxiliary personnel under the billing practitioner's general supervision, including employees, contractors or leased staff. Direct supervision is not required.

CMS lists separate APCM consent elements, so get and document an APCM-specific consent. Suggested practice policy: treat consent as program-specific whenever the program changes.

You cannot bill Medicare or the patient. An Advance Beneficiary Notice (ABN) is not appropriate, because CCM is a covered service.

CMS does not define consent from a representative. Suggested practice policy: if the patient cannot consent, obtain consent from the legally authorized representative before billing, and record who gave it and their authority. A facility's general consent to treat is not enough.

One. Only 1 practitioner can bill CCM in a calendar month, APCM in a calendar month, TCM in a 30-day period, and RPM or RTM in a 30-day period. For TCM, Medicare pays the first eligible claim it receives.

Never. Minutes counted toward one code cannot count toward any other billed code, whether face-to-face or not (CMS CCM FAQ).

No. Medicare pays the PFS amount for each code billed (80% from Medicare, 20% patient coinsurance), adjusted for locality. Services billed by a nurse practitioner, clinical nurse specialist or physician assistant are paid at 85% of the physician rate (CMS APRN billing page).

For CCM, yes: 20 to 39 minutes supports 99490 only; 40 to 59 adds 1 unit of 99439; 60+ adds 2 (AAPC). For BHI and CoCM, CMS says CPT time rules apply (CMS BHI booklet).

Yes, and CMS expects them to: services should continue as medically necessary even after the billed code's minutes are reached (CMS CCM FAQ).

Within 2 business days after discharge. If 2 or more separate, timely attempts fail and are documented, TCM may still be billed if everything else is met. CMS expects attempts to continue until successful.

Either. The physician or NPP, or clinical staff under their direction, may make it. The contact must be made by clinical staff who can address the patient's status and needs beyond scheduling follow-up care. A scheduler or front-desk call that only books an appointment does not meet the requirement. Medical assistants may perform parts of TCM if state law, scope of practice and incident-to rules allow.

The deadline is 7 calendar days for 99496 (high MDM) and 14 calendar days for 99495 (moderate MDM). Suggested practice policy: book the visit during the first contact call, and aim for day 7 so either code remains available. If the visit misses the window, TCM cannot be billed; bill the visit as a regular E/M.

A physician (any specialty) or NPP (NP, PA, CNS, CNM). It can be done by telehealth. If furnished incident-to, it requires direct supervision; the rest of TCM can be under general supervision. It can't be on the same day the same practitioner bills discharge day management.

Yes. The same practitioner may bill hospital or observation discharge services and TCM.

Communicate with the patient, family and agencies; educate for self-management and daily living; support treatment and medication adherence; identify community resources; help access care.

Review discharge information, review or follow up on tests and treatments, interact with other clinicians who will assume care, educate the patient or caregiver, arrange referrals and community resources, and help schedule follow-up. They must also make the moderate or high MDM.

TCM can still be billed once, covering the services furnished across the period, including after the second discharge. Alternatively, bill TCM for a full 30 days after the second discharge, as long as nobody billed it for the first. The same individual or group cannot bill another TCM for any later discharge within 30 days.

CMS sets no annual limit. The limit is once per patient per 30-day period by one practitioner. A patient with discharges in February, June and October, each outside an existing TCM period, can support 3 TCM services if each meets all requirements.

Do not bill TCM. Bill the face-to-face visit as an E/M.

Medicare pays the first eligible claim; others can still bill medically necessary E/M visits.

Yes, including separate E/M visits for clinical issues (other than the required face-to-face visit), CCM, and the services listed in Section 5.

The location of the face-to-face visit.

Discharge date; date of first interactive contact (and failed attempts); face-to-face visit date; MDM level.

Use PIN when the focus is guiding a patient through care for one serious illness, such as a new cancer diagnosis. Use CHI when a social barrier, such as no transportation to dialysis, is what stops treatment from working. PIN may also address social needs, but CHI requires them.

Not for the same condition.

For incident-to services, the supervising physician or NPP must use their NPI to bill; an NP or PA billing their own services uses their own NPI (CMS APRN billing page). Medicare pays NP and CNS services, and incident-to services they supervise, at 85% of the physician amount (same page).

CCM must be initiated by the billing practitioner, for new patients or those not seen by that practitioner in the past year (CMS CCM FAQ). For APCM, auxiliary personnel work incident-to the provider who bills the initiating visit (if required) and the APCM services (CMS APCM page). Auxiliary personnel may be employees, leased employees or contractors, must meet state licensure, and must not be excluded or revoked (CMS APCM page).

Report the location where the billing practitioner would ordinarily see the patient face-to-face. This applies to patients in SNFs, nursing facilities and assisted living (CMS CCM FAQ; CMS APCM FAQ).

Yes. CCM is priced for facility and non-facility settings; use the place of service where the billing practitioner would ordinarily see the patient (CMS CCM FAQ).

For 99490/99439 and 99491/99437, either the end of the month or the date the time threshold was met. For complex CCM (99487/99489), report at the end of the month, since MDM is judged across the whole month (CMS CCM FAQ).

Yes, if the required minutes were met that month and all other requirements are met. TCM is different: it cannot be billed if the patient dies before day 30 (CMS CCM FAQ; CMS TCM FAQ).

Split it. Thirty minutes benefiting 3 CCM patients counts as 10 minutes each (CMS CCM FAQ).

Yes, if they are within the CCM scope and not counted toward any other billed code, such as an E/M visit (CMS CCM FAQ).

Yes, as clinical staff under incident-to rules and their scope of practice, though they cannot bill CCM themselves (CMS CCM FAQ).

Medigap must pay its share. For Qualified Medicare Beneficiaries, Medicaid is responsible, but many states pay little or nothing under "lesser-of" rules; you cannot bill QMB patients for the difference (CMS CCM FAQ).

CMS lists typical elements (problem list, expected outcome and prognosis, measurable goals, cognitive and functional assessment, symptom management, planned interventions, medical management, environmental evaluation, caregiver assessment, coordination with outside resources), not a strict checklist. The plan must be electronic, available within and outside the practice, and shared with the patient (CMS CCM FAQ; CMS CCM booklet).

Yes for CCM and APCM: patients must be able to reach a practitioner or clinical staff for urgent needs at any time, and have a designated care team member for routine appointments (CMS CCM booklet; CMS APCM page).

Yes for CCM: demographics, problems, medications and allergies must be recorded in certified EHR technology (CMS CCM booklet).

No. If they are already recorded as structured data from the initiating visit, the requirement is met. They must stay current, though, because CCM includes medication review and oversight.

• When CCM finds a change (new med, stopped med, new allergy, new problem), update the structured EHR list. Don't record it only in a third-party PDF note.
• When nothing changed, the monthly note can say "meds and allergies reviewed, no changes," with the date and the reviewer.

Yes: contact the patient or caregiver within 7 days of discharge from an ED, hospital, SNF or other facility, as clinically indicated (CMS APCM page).

Yes: report the Primary Care MIPS Value Pathway, or participate in a Shared Savings Program ACO or a listed CMS primary care model (CMS APCM page).

Yes, paid at the PFS non-facility rate, with or without a qualifying visit (CMS APCM FAQ).

Only if the specialist really is the patient's primary care practitioner. CMS doesn't restrict APCM by specialty; it restricts it by role (CMS APCM page). The billing practitioner must:

• Be responsible for all of the patient's primary care.
• Be the continuing focal point for all needed health care services.
• Be able to furnish every APCM element every month, including 24/7 access, the comprehensive care plan, care transitions, population-level management and enhanced communication.
• Report the Primary Care MIPS Value Pathway, or participate in a Shared Savings Program ACO or a listed CMS primary care model.

CMS expects primary care specialties (internal medicine, family medicine, geriatrics, pediatrics) to use APCM most; that is an expectation, not a ban. A specialist could qualify when acting as the full primary care home, for example a nephrologist for a dialysis patient. A specialist managing one or a few conditions (a cardiologist for heart failure, an endocrinologist for diabetes) should use PCM or CCM instead. A specialist may bill CCM or PCM in the same month the primary care practitioner bills APCM, because the same-month restriction applies only to the APCM practitioner (Bass Berry).

Yes. Medicare and CPT allow E/M visits during the CCM service period; CCM pays for non-face-to-face management and the E/M pays for the in-person visit, even when both address the same chronic condition (CMS CCM FAQ). Bill both only when:

• The visit is separately medically necessary: the E/M note shows why the patient had to be seen in person.
• No minute counts twice. Visit time never counts toward CCM. If the E/M is coded by total time, same-day pre- and post-visit work belongs to the E/M, not the CCM log.
• CCM work on the same day counts only if it is within the CCM scope and not counted toward the E/M (for example, the earlier call that identified the problem and arranged the visit).
• The CCM threshold (20 minutes for 99490, 30 for 99491) is met from non-visit work.
• Complex CCM (99487/99489) is not billed in a month with prolonged E/M services (CMS CCM booklet). A routine 99213 is fine.

The same logic applies to the other programs. In TCM, the required face-to-face visit is part of TCM, but any additional medically necessary E/M visits in the 30 days are billed separately (CMS TCM booklet). Office visits are not part of the APCM bundle, so they are billed normally; only the excluded codes in Section 5 are barred. PCM, BHI and RPM follow the same no-double-counting rule.