2023
Coding for Care Management and Other Non-Direct Services
Primary care services often take place when the patient or family is not present in the office. In addition,
caring for children with complex chronic medical issues is extremely time-consuming, with much of the
time spent not always by the physician but by clinical staff in the practice doing non-direct care
coordination services. The resource will review many non-direct services provided to pediatric patients,
including the most fragile population. Not all services listed here require chronic medical conditions,
however.
Remember that some of these children are very clinically complex, and it is important to capture all details
in their diagnostic picture (eg, by reporting all applicable ICD-10-CM codes).
Topics:
Prolonged Non-Direct E/M Services
Transitional Care Management
Chronic Care Management
Principal Care Management Services
Care Plan Oversight
Prolonged Non-Direct E/M Service
Online Digital E/M Services
Telephone Care
Interprofessional Consultation
Medical Team Conference
This is for reporting time on a date other than the date of a related evaluation and management service even
if the time spent by the physician or other QHP on that date is not continuous..
99358 Prolonged evaluation and management service before and/or after direct patient care; first hour
(minimum 30 minutes)
+ 99359 each additional 30 minutes (minimum 15 minutes) (List separately in addition to code 99358)
• Report 99358-99359 for the total duration of non-face-to-face time spent by a physician or other QHP
on a given date providing prolonged service.
• Not reported when the same time is attributed to another reported service (eg, medical team
conference or interprofessional telephone/internet/EHR consultation).
• Not reported for time spent by clinical staff or on activities generally performed by clinical staff (eg,
reviewing test results with a patient).
Transition Care Management and Care Management
Reported under the directing physician or other QHP, however, the time requirement can be met by clinical
staff working under the direction of the reporting physician or other QHP.
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
Transition Care Management
Transition care management (TCM) are for a patient whose medical and/or psychosocial problems require
moderate or high complexity medical decision-making (MDM) during transitions in care from an inpatient
hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial
hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community
setting (home, domiciliary, rest home, or assisted living). TCM commences on the date of discharge and
continues for the next 29 days and requires a face-to-face visit, initial patient contact, and medication
reconciliation within specified timeframes. Any additional E/M services provided after the initial may be
reported separately. Refer to table 1 for quick reference of timing of initial visit and MDM required.
Refer to the CPT manual for complete details on reporting care management and TCM services.
o Do not report for patients “discharged” from the emergency department.
99495 Transitional care management services with the following required elements:
▪ Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2
business days of discharge
▪ Medical decision-making (MDM)of at least moderate complexity during the service period
▪ Face-to-face visit, within 14 calendar days of discharge
99496
Transitional care management services with the following required elements:
▪ Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2
business days of discharge
▪ Medical decision-making of high complexity during the service period
▪ Face-to-face visit, within 7 calendar days of discharge
Table 1 - TCM Table of MDM
Level of MDM
First face-to-face within 7
days of discharge
First face-to-face within
14 days of discharge
Moderate
99495
99495
High
99496
99495
Chronic Care Management Services
Codes are selected based on the amount of time spent by clinical staff of the physician or other QHP
providing care coordination activities. CPT clearly defines what is care coordination activities. In order to
report chronic care management (CCM) or complex chronic care management codes (CCCM), you must
1. provide 24/7 access to physicians or other QHPs or clinical staff;
2. use a standardized methodology to identify patients who require chronic complex care coordination
services
3. have an internal care coordination process/function whereby a patient identified as meeting the
requirements for these services starts receiving them in a timely manner
4. use a form and format in the medical record that is standardized within the practice
5. be able to engage and educate patients and caregivers as well as coordinate care among all service
professionals, as appropriate for each patient.
For a brief overview of the CCM/CCCM services see table 2.
For patients with only one chronic condition, refer to Care Plan Oversight or Principal Care
Management. Note these codes require time is spent by the provider, not clinical staff.
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
99490
Chronic care management services with the following required elements:
• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death
of the patient,
• chronic conditions place the patient at significant risk of death, acute exacerbation/
decompensation, or functional decline,
• comprehensive care plan established, implemented, revised, or monitored;
first 20 minutes of clinical staff time directed by a physician or other QHP, per calendar month.
o Do not report 99490 for chronic care management services that do not take a minimum of 20 minutes
in a calendar month.
+ 99439 each additional 20 minutes of clinical staff time directed by a physician or other qualified health
care professional, per calendar month (List separately in addition to code 99490)
o Chronic care management services of 60 minutes or more and requiring moderate or high complexity
medical decision making may be reported using 99487, 99489
o Do not report 99439 more than twice per calendar month
o Do not report 99490 and/or 99439 in the same calendar month as 99491
99491 Chronic care management services, provided personally by a physician or other QHP, at least 30
minutes of physician or other QHP time,
per calendar month, with the same elements as 99490 (see above)
• Do not report 99491 in the same calendar month as 99490 or 99439
o Do not report 99439, 99490 or 99491 in the same calendar month with 90951-90970, 99339,
99340, 99374, 99375, 99377, 99378, 99379, 99380, 99487, 99489, 99605, 99606, 99607
o Do not report 99439, 99490 or 99491 for time spent in other separately reportable services
Complex Chronic Care Management Services
Complex chronic care management is reported by the physician or QHP who provides or oversees the
management and coordination of all of the medical, psychosocial, and daily living needs of a patient
with a chronic medical condition. Typical pediatric patients
1. receive three or more therapeutic interventions (eg, medications, nutritional support,
respiratory therapy)
2. have two or more chronic continuous or episodic health conditions expected to last at least 12
months (or until death of the patient) and places the patient at significant risk of death, acute
exacerbation or decompensation, or functional decline
3. commonly require the coordination of several specialties and services.
99487 Complex chronic care management services with the following required elements:
• multiple (two or more) chronic conditions expected to last at least 12 months, or until the death
of the patient,
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
• chronic conditions place the patient at significant risk of death, acute exacerbation/
decompensation, or functional decline,
• comprehensive care plan established, implemented, revised, or monitored,
• moderate or high complexity medical decision making;
first 60 minutes of clinical staff time directed by a physician or other QHP, per calendar month.
Do not report 99487 for chronic care management services that do not take a minimum of 60 minutes in a
calendar month.
+99489 each additional 30 minutes of clinical staff time directed by a physician or other QHP, per
calendar month (Report with 99487)
Table 2 – Overview of CCM/CCCM
Time (minimum)
Performing provider
Services
20 m/month
Clinical staff w/ physician direction
CCM
Addt’I 20 m/month
beyond 99490
Clinical staff w/ physician direction
CCM
20 m/month
Physician or other QHP
CCM
60 m/month
Clinical staff w/ physician direction
(may include physician or QHP time)
CCCM
Each add’tl 30 m/month
beyond 99487
Clinical staff w/ physician direction
(may include physician or QHP time)
CCCM
m, minute. + add on code.
Principal (Single-Disease) Care Management Services
1. A single (1) 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
2. A condition that requires the development, monitoring, or revision of a disease-specific care plan,
3. A condition that requires frequent adjustments in the medication regimen and/or the management
of the condition is unusually complex due to comorbidities
4. Different physicians or QHPs may report ongoing communication and care coordination between
relevant practitioners furnishing care in the same calendar month for the same patient
5. Documentation in the patient’s medical record should reflect coordination among relevant managing
clinicians
6. Principal care management services are disease-specific management services. Even if a patient may
have multiple chronic conditions, they may receive principal care management if the reporting
physician or other QHP is providing single disease rather than comprehensive care management
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
99424 Principal care management services, for a single high-risk disease, with the following 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 provided personally by a physician or other QHP, per calendar month.
+ 99425 each additional 30 minutes provided personally by a physician or other qualified health care
professional, per calendar month (List separately in addition to 99424)
99426 Principal care management services, for a single high-risk disease, with the following 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 physician or other qualified health care professional,
per calendar month.
+ 99427 each additional 30 minutes of clinical staff time directed by a physician or other QHP, per calendar
month (List separately in addition to code 99426)
Table 3- Principal Care Management
Code
Staff Type
Minimum Time Required
Time Span
Max Per Month
99424
Physician or QHP
30 minutes
30-59 mins
1
+99425
Physician or QHP
60 mins (per 30 mins)
60-89 mins X 1
90-119 mins X 2 (etc)
No limit
99426
Clinical staff
30 mins
30-59 minutes
1
+99427
Clinical staff
60 mins (per 30 mins)
60-89 mins X 1
90-119 mins X 2
2
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
Care Plan Oversight (CPO)
The following per month codes are for physician time only. The patient only needs one chronic medical
condition.
99339 Individual physician supervision of a patient (patient not present) in home, domiciliary or rest
home (e.g., assisted living facility) requiring complex and multidisciplinary care modalities
involving regular physician development and/or revision of care plans, review of subsequent
reports of patient status, review of related laboratory and other studies, communication
(including telephone calls) for purposes of assessment or care decisions with health care
professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key
caregiver(s) involved in patient’s care, integration of new information into the medical
treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
99340 30 minutes or more
99374 Care plan oversight services requiring complex and multidisciplinary care modalities involving
regular physician development and/or revision of care plans, review of subsequent reports and
related lab studies, communications, integration of new information into treatment plan, and/or
adjustment of medical therapy, patient under care of home health agency, 15-29 min.
99375 30 min. or more
99377 Care plan oversight services, patient under care of hospice, 15-29 min.
99378 30 min. or more
99379 Care plan oversight, patient in a nursing facility, 15-29 min.
99380 30 min. or more
Care Plan Oversight FAQ
Q. If time is spent by my clinical staff, may I count that?
A. No CPO requires that the work be done by a physician or QHPs who may independently bill
under their own name and NPI.
Q. If more than one physician or QHP works on a care plan in the same calendar month, may they
both bill for their time?
A. No, most payers consider physicians or QHPs who work in the same group practice in the same
specialty to be the “same”; therefore, the time would have to be combined and billed only once
per calendar month.
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
Online Digital Evaluation and Management Service
These are patient-initiated services with physicians or other QHPs (QHPs) who can report E/M services.
Online digital E/M services require a physician or other QHP’s evaluation, assessment, and management of
the patient. They are not for the non-valuative electronic communication of test results, scheduling of
appointments, or other communication that does not include E/M. These are more appropriate when dealing
with a more minor issue or during a month when you are not coding or providing more robust care; thus,
this time would be reported under another service like care management.
• Patient must be established (problem can be new)
• Services must be initiated through Health Insurance Portability and Accountability Act (HIPAA)-
compliant secure platforms
• Reported once for the physician’s or other QHP’s (including all in the same group practice) cumulative
time during a seven-day period
• The seven-day period begins with the physician’s or other QHP’s initial, personal review of the
patient-generated inquiry.
• Online digital E/M services require permanent documentation storage (electronic or hard copy) of the
encounter.
• Do not report these codes separately if the patient is seen within 7 days of the service for an issue
related to the encounter.
• Your date of service will be the date the initiation of the e-visit began or the range of dates it took
place because this service is cumulative time over 7 days.
99421 Online digital evaluation and management service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 5-10 minutes
99422 11-20 minutes
99423 21 or more minutes
• Do not report 99421, 99422, 99423 when using 99091, 99339, 99340, 99374, 99375, 99377, 99378,
99379, 99380, 99487, 99489 for the same communication[s]
• Do not report 99421, 99422, 99423 on a day when the physician or other QHP reports E/M services
[99202 – 99205, 99212 - 99215, 99242– 99245]
The following codes are reported by nonphysician providers who may independently bill such as physical
therapists and psychologists, but are not reported for clinical staff (eg, RN) unless noted in writing by your payer.
98970 Qualified nonphysician health care professional online digital evaluation and management service, for
an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
98971 11-20 minutes
98972 21 or more minutes
Online Digital E/M FAQ
Q. Who is a “qualified nonphysician healthcare professional?
A. This professional will be able to bill under his/her own NPI, but not be eligible to bill an E/M
service. An example might be a psychologist.
Q. If a parent or patient, within the 7 days of initiating an online E/M service, brings up a new
problem, does the “clock” start over -meaning I can bill for 2 distinct online digital E/M services?
A. No. Unfortunately, the “clock” runs for the full 7 days from initiating the digital service. Therefore,
only online digital E/M service may be billed per 7 days, regardless of how many conditions are
addressed. If, however, after the 7 days, a new portal or other electronic communication is started
to address a new or existing issue, the clock may begin again. You can report another online digital
E/M service if the patient is not seen in the office or via telemedicine.
Q. We have a mom who reached out to our physician via a portal. Four days later, the patient had a
related telemedicine service that we billed for. Can we still report the online digital E/M service?
A. No – you cannot bill the digital online E/M service separately.
Q. A patient was seen 8 days prior for an incision and drainage. The code we reported has a 10-day
global. Can we still separately report the online digital E/M encounter related to the procedure since
it was more than 7 days later?
A. No – you are still within the global period. Per CPT, “If the online digital inquiry is related to a
surgical procedure and occurs during the postoperative period of a previously co mpleted
procedure, then the online digital E/M service is not reported separately.
Q. A patient-initiated an online inquiry with our physician about a new medical concern. The patient
was seen 5 days ago for an ankle injury, and today’s encounter addressed a trunk rash. May we bill
the time separately?
A. Yes. Per CPT, “If the patient generates the initial online digital inquiry for a new problem within
seven days of a previous E/M visit that addressed a different problem, then the
online digital E/M service may be reported separately.”
Q. If there is more than one provider involved in the message thread, do you add them up and bill
under one provider, or do each separately? If one provider, how do you pick which one?
A. Per CPT, “All professional decision-making, assessment, and subsequent management by
physicians or other QHPs in the same group practice contribute to the cumulative service time of
the patient’s online digital E/M service.” Therefore, you only bill under one. How you determine
which physician will be up to your practice policy or if you could bill under the practice instead.
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
Telephone Care Services
Telephone care, regardless of provider, must be initiated by the parent, patient or guardian. The
telephone call cannot be related to an E/M service within the previous 7 days, nor can they lead to
an appointment within the next 24 hours or the soonest available. This is not telehealth or
telemedicine. Your date of service will be the date the phone call takes place.
99441
Telephone evaluation and management to patient, parent or guardian not originating from a
related E/M service within the previous 7 days nor leading to an E/M service or procedure within
the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
99442
11-20 minutes of medical discussion
99443
21-30 minutes of medical discussion
The following codes are reported by nonphysician providers who may independently bill such as physical
therapists and psychologists, but are not reported for clinical staff (eg, RN) unless noted in writing by your
payer.
98966 Telephone assessment and management service provided by a qualified nonphysician healthcare
professional to an established patient, parent or guardian not originating from a related
assessment and management service provided within the previous seven days nor leading to an
assessment and management service or procedure within the next 24 hours or soonest available
appointment; 5-10 minutes of medical discussion
98967 11-20 minutes of medical discussion
98968 21-20 minutes of medical discussion
Telephone Care FAQ
Q. If a mom calls and speaks with provider A in the morning and calls back later that same day and speaks to
the same or a different provider, may we report the telephone care code twice? Would it matter if the services
were related or unrelated?
A. In this case, you would combine the time and report only one telephone care service regardless of
providers (so long as they are in the same group practice/specialty) or issues addressed. The calls happened
on the same calendar day, and payers will most likely deny the 2 separate calls. While you could submit with
two distinct ICD-10-CM codes, most payers will deny it.
Interprofessional Telephone/Internet/Electronic Health Record Consultations
An interprofessional telephone/internet/EHR consultation (ITC) is an assessment and management service in
which a patient’s treating (eg, attending or primary) physician or other QHP requests the opinion and/or
treatment advice of a physician with specific specialty expertise (the consultant) to assist the treating
physician or other QHP in the diagnosis and/or management of the patient’s problem without patient face-
to-face contact with the consultant.
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
• The patient may be either a new patient to the consultant or an established patient with a new problem or an
exacerbation of an existing problem
• The consultant cannot have seen the patient within the last 14 days
• If the ITC leads to a transfer of care, these codes cannot be used if the consultant sees the patient (eg, visit or
surgery) within the next 14 days or the soonest available appointment of the consult.
• Codes include a review of pertinent medical records, laboratory and/or imaging studies, medication profiles,
pathology specimens, etc, however, for codes 99446-99449, the majority of the service time reported (greater
than 50%) must be devoted to the medical consultative verbal or Internet discussion.
• Codes 99446-99449, and 99451 should not be reported more than once within a seven-day interval;
therefore, if time is spent over multiple days, count the total time and report one code.
• A summary table is included to help navigate the appropriate use of the codes. See table 3
99446 Interprofessional telephone/Internet/electronic health record assessment and management service
provided by a consultative physician, including a verbal and written report to the patient’s
treating/requesting physician or other QHP; 5-10 minutes of medical consultative discussion and review
99447 11-20 minutes of medical consultative discussion and review
99448 21-30 minutes of medical consultative discussion and review
99449 31 minutes or more of medical consultative discussion and review
99451 Interprofessional telephone/Internet/electronic health record assessment and management service
provided by a consultative physician, including a written report to the patient’s treating/requesting physician
or other QHP, 5 minutes or more of medical consultative time
99452 Interprofessional telephone/Internet/electronic health record referral service(s) provided by a
treating/requesting physician or other QHP, 30 minutes
• Use prolonged services (99358-99359) instead if the time spent exceeds 30 mins on a single
calendar day
• Only report once per 14 days
Table 3 - ITC Summary Table
ITC Code
Time
Written Report
Verbal report
Who Reports?
99446
5-10m
√
√
Consultative physician
99447
11-20m
√
√
Consultative physician
99448
21-30m
√
√
Consultative physician
99449
>30m
√
√
Consultative physician
99451
5m >
√
Consultative physician
99452
16m>
√
Treating/Requesting provider
+ Codes are add-on codes, meaning they are reported separately in addition to the appropriate code for the service provided
Current Procedural Terminology® 2023 American Medical Association. All Rights Reserved.
Medical Team Conference
This code is reported when a minimum of 3 QHPs meet without the patient or family present in any
setting. If the patient or family is present, the physician will report the appropriate E/M service.
These codes cannot be reported in addition to the per-day critical or intensive care service codes.
Code 99367 is for physicians, while 99368 is for QHPs when the patient or family is not present.
Code 99366 is only for the QHP when the patient or family is present. A physician or advanced
practitioner would report an E/M service (eg, 99214) as appropriate.
99366 Medical team conference with interdisciplinary team of health care professionals, face-to-face with
patient and/or family, 30 minutes or more, participation by nonphysician QHP
99367 Medical team conference with interdisciplinary team of health care professionals, patient and/or
family not present, 30 minutes or more; participation by physician
99368 Medical team conference with interdisciplinary team of health care professionals, patient and/or
family not present, 30 minutes or more participation by nonphysician QHP
• Do not report 99366, 99367, 99368 during the same month with 99439, 99487, 99489, 99490,
99491