Be it illness, disability, or death, chronic diseases are to be blamed. What’s worse is that 4 in 10 people in the U.S. have two or more chronic diseases. So, what can healthcare providers do to reduce the burden these chronic conditions pose on the healthcare system, from emergency visits to hospitalization and body preparation? The answer lies in their proper management.
That’s why, in today’s detailed guide, we will dissect CPT code 99487, which is used for complex chronic care management when a patient has two or more chronic conditions. So, let’s explore the code’s descriptor, use cases, applicable modifiers, and billing tips.
CPT Code 99487 – Description
The Current Procedural Terminology (CPT) code 99487 is under the ‘Complex Chronic Care Management Services’ code range, as maintained by the American Medical Association (AMA). It reports the first 60 minutes of complex chronic care management (CCCM) services, which are provided under the direct supervision of a physician or another qualified healthcare professional.
The code is specifically used when a patient has two or more chronic conditions that necessitate immediate medical attention and intervention. According to the code’s description, these conditions must:
- Be placing the patient at significant risk of death,
- Acute exacerbation,
- Decompensation, or
- Functional decline
Therefore, CPT code 99487 is used for the management of high-risk chronic conditions and must be reported once per calendar month. Also, one-on-one or in-person clinical staff time is mandatory for this code to be valid. Thus, this code is not applicable if CCCM services were delivered via telehealth platforms in the absence of all clinical staff.
Now, let’s also understand who qualifies as the “clinical staff” in this case. So, in the CPT Codebook, clinical staff are defined as:
“A person who works under the supervision of a physician or other qualified healthcare professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.”
Hence, the following can be considered clinical staff:
- Advanced Practice Registered Nurses (APRNs)
- Registered Nurses (RNs)
- Licensed Specialist Clinical Social Workers (LSCSWs)
- Licensed Practical Nurses (LPNs)
- Certified Medical Assistants (CMAs)
- Pharmacists
You must report the direct one-on-one time they spent with the patient for accurate billing of CPT code 99487. However, this staff will use the “incident to” billing rule for Medicare claims and reimbursement collection. We will discuss this in detail later in the blog.
Some other prerequisites that must be met for this code to be valid include:
- The two or more high-risk chronic conditions are expected to last at least 12 months or until the patient’s death.
- During the 60-minute session, a comprehensive care plan is established, implemented, revised, or monitored.
- Moderate to high complexity medical decision-making.
- Care management across multiple specialties.
Note that in CY2025, Medicare is reimbursing physicians for CPT code 99487 at $131.65 in non-facility settings and $87.01 in facility settings.
Scenarios Where CPT Code 99487 is Applicable
We tried to give you a lowdown on CPT code 99487’s description, including who can use it for billing and under what conditions. However, if you are still confused about the code’s accurate usage, read through the following examples as we focus on a few clinical situations where CPT 99487’s usage makes perfect sense.
Chronic Kidney Disease, Heart Failure, and Type II Diabetes
Did you know that nearly 16% of patients with heart failure (HF) also have diabetes mellitus (DM) and chronic kidney disease (CKD) simultaneously? In fact, the three conditions are interlinked and share the same risk factors, e.g., obesity, inflammation, high blood sugar, and high blood pressure. The presence of these three comorbidities (chronic conditions) increases the risk of hospitalization and death. Therefore, healthcare providers are compelled to offer such patients complex chronic care management services to reduce the mortality rate.
Considering these facts and stats, let’s assume that an 80-year-old man in an assisted living facility has diabetes and chronic kidney disease, which led to his heart failure. To manage the symptoms and complications of these high-risk chronic conditions, a 60-minute initial CCCM session was scheduled with a care team that included a cardiologist, nephrologist, and endocrinologist. The three specialists supervised a registered nurse at the facility, and after high complexity medical decision-making, a comprehensive care plan was created for the patient. Thus, the service was billed with CPT code 99487.
Chronic Obstructive Pulmonary Disease and Asthma
Physicians are known to invent their own terminology to simplify medical lingo and internal communication. You can see this play out in the case of asthma-COPD overlap syndrome (ACOS). A term that is used to describe the presence of both asthma and chronic obstructive pulmonary disease (COPD) in one patient.
Studies have shown that the prevalence of ACOS in the U.S. is approximately 3.2%. Again, the presence of both these comorbidities (chronic conditions) increases ED visits and hospitalizations. Hence, physicians prefer timely treatment and management via CCCM services.
So, for our next example, consider a 68-year-old man with severe respiratory symptoms like increased wheezing, coughing, mucus production, and breathlessness. He has a history of asthma and smoking-related COPD. Looking at his high-risk conditions, an on-site registered nurse attends to the patient while receiving instructions from a pulmonologist. The visit lasts 75 minutes and includes condition assessment, moderate complexity medical decision-making, and creation of a detailed care plan. Hence, it is billed with CPT code 99487 for reimbursement.
Cancer and Chronic Pain
One of the long-term effects of cancer treatment is chronic pain. According to one U.S.-based study, the prevalence of chronic pain in cancer survivors is around 34.6% and nearly 16.1% experience high-impact chronic pain (HICP), which impairs their quality of life. Therefore, proper treatment and management are required so patients can resume their activities of daily living.
Based on this information, let’s imagine a 60-year-old female survivor of breast cancer who underwent multiple rounds of chemotherapy and a surgery. However, she now experiences musculoskeletal pain post-mastectomy mainly because of aromatase inhibitors. From joint pain to muscle aches and stiffness, she experiences everything.
Therefore, a licensed practical nurse meets the patient for 60 minutes. Under the direct supervision of an oncologist and a qualified pain management expert, she analyzes the patient’s chronic conditions. She then communicates the specialists’ decision to the patient, including a detailed care plan. Hence, CPT code 99487 is reported for billing purposes.
Applicable Modifiers for CPT Code 99487
Modifiers are two-digit codes that enable special circumstance coding. In other words, modifiers provide supplemental information to the insurance payer, helping them understand the special circumstances in which a procedure was performed. Some, known as payment modifiers, affect the final reimbursement rate.
Therefore, we have listed a few modifiers that are commonly appended to CPT code 99487 for accurate billing. Take a look!
Modifier 22 – Increased Procedural Service
CPT code 99487 in itself is a comprehensive code that covers multiple steps of complex chronic care management. However, in some instances, the supervising physician and on-site auxiliary/ clinical staff may be required to do more than what is typically indicated by this code. So, when providers spend more time and effort than the standard, modifier 22 is appended to CPT code 99487 to highlight increased complexity.
Modifier 59 – Distinct Procedural Service
If you rendered another procedure or service on the same day as complex chronic care management, use modifier 59 or one of its suitable subsets – X{EPSU} modifiers – with CPT code 99487 to explain that the CCCM service is distinct and separately reimbursable. It helps you bypass the NCCI edits and avoid duplicate claim denials.
Modifier 95 – Telehealth Service
During the COVID-19 public health emergency, the Centers for Medicare and Medicaid Services (CMS) allowed providers to deliver chronic care management (CCM) services via telehealth platforms. Even today, Medicare allows this practice in special circumstances.
So, if the supervising physician or other qualified healthcare professional directed the clinical staff for CCCM service delivery using an approved telehealth platform, append modifier 95 to CPT code 99487 to highlight this.
Modifier 95 explains that a synchronous telemedicine service was rendered in real-time through an interactive audio-video telecommunications system.
CPT Code 99487 – Billing & Reimbursement Guidelines
Eager to collect reimbursement for your services? And why not? You deserve it! But was your claim for CPT code 99487 denied even after the correct code selection? The problem might be your billing practices.
Here are some key billing guidelines related to CPT code 99487 that are likely to increase your chances of clean claim submissions and fair reimbursements. So, read through.
Use CPT Code 99487 Correctly
The first billing rule that you must follow is to fulfill all the requirements of CPT code 99487. So, instead of confusing it with other chronic care management codes (99437, 99439, 99490, 99491) or complex chronic care management code (99489), you must ensure that your service includes the following elements:
- The patient has two or more chronic conditions.
- The conditions are expected to last at least 12 months or until the patient’s death.
- The patient is at risk of death, functional decline, or acute exacerbation/decompensation.
- Involved moderate to high complexity medical decision-making.
- A comprehensive care plan was created or revised.
- 60 minutes of direct clinical staff time.
- Supervising physician(s) were involved in the process.
- The CCCM service was the first 60 minutes of contact with the patient in that month.
Report the Time Clinical Staff Spent with the Patient
For reporting one unit of CPT code 99487, you must ensure that the clinical staff, not the supervising physician, spent at least 60 minutes (1 hour) with the patient. The duration can stretch to 89 minutes (1.5 hours) for the same one unit to be applicable. However, if additional time is required, you should report code 99487 with the add-on code 99489 for each additional 30 minutes of CCCM service.
Bill as ‘Incident To’ for Medicare Claims
Please bear in mind that the auxiliary or clinical staff delivering the CCCM service cannot bill CPT code 99487 under their name. Instead, they must bill the services ‘incident to’ or under the supervising physician’s NPI. Note that Medicare will only count the time spent by the clinical staff rendering CCCM services if the billing follows the ‘incident to’ rules.
Bill Once per Calendar Month
You must also remember that CPT code 99487 can only be reported once in 30 days for the same patient.
Provide Comprehensive Documentation
Complete and accurate documentation is an essential billing requirement. It helps the payer understand the medical necessity of a service. Therefore, your claims for CPT code 99487 should include the following as supporting documentation:
- The patient’s complete medical record, including details of the chronic conditions
- Current condition and symptoms, including the appropriate ICD-10 codes
- Clear identification of supervising physician(s)
- Clear identification of attending clinical staff
- Clinical notes including the assessment of the patient’s conditions, decisions made, and suggested care plan
- Accurate reporting of the time spent
- A copy of the care plan
- A copy of the signed physician report
- Telehealth platform used for supervision (if applicable)
Do Not Bill These Services in the Same Calendar Month as 99487
When it comes to filing Medicare claims for CPT code 99487, there are some procedural codes that you CANNOT bill in the same month as 99487. This is because the services represented by those codes are already covered under CPT code 99487. So, billing both those codes in the same calendar month would be the same as billing 99487 twice (or more than once) in 30 days, which we know is not allowed.
The codes that you cannot bill in the same month as CPT code 99487 are:
- HCPCS G0181 – Home Healthcare Supervision
- HCPCS G0182 – Hospice Care Supervision
- CPT Codes 90951-90970 – End-Stage Renal Disease (ESRD) Services
Medicare also advises against reporting CPT code 99487 in the same month as:
- CPT Code 99437
- CPT Code 99439
- CPT Code 99490
The advisory is issued in light of potentially duplicative billing.
Summary
Did we cover the ground running? If yes, did it feel like you whizzed past a few essential details? Don’t worry, we will summarize the key takeaways for you right away. First, we discussed that CPT code 99487 reports a complex chronic care management service that lasts 60 minutes and includes physician supervision. However, a clinical staff member renders the service. It involves moderate to high complexity medical decision-making and care plan creation for a patient with two or more chronic diseases.
We also discussed some clinical scenarios where CPT 99487 can be used for accurate billing, such as managing a patient with heart failure, chronic kidney disease, and diabetes. Next, we uncovered some modifiers that are typically appended to this CPT code. For example, modifiers 22, 59, and 95. Lastly, we discuss some key billing tips that will ensure clean claim submission for CPT code 99487. If you are still confused, don’t let it divert your attention from quality patient care. Explore tailored CCM billing services and let experts handle the rest.
