The Medicare Chronic Care Management (CCM) and Transitional Care Management (TCM) programs were established to incentivize the provision of additional and needed services to eligible individuals covered by the Medicare Fee-For-Service program. The purpose of this article is to demonstrate that “appropriately educated and credentialed medical assistants” are considered clinical staff under the Centers for Medicare & Medicaid Services (CMS) CCM and TCM regulations and policy documents; therefore, certain services of these medical assistants can be billed incident to the services of the billing physician or nonphysician practitioner (NPP).

(Note: Appropriate medical assisting education and credentialing covers the clinical and administrative knowledge, skills, and professional attributes required for the competent and safe practice of medical assisting.)

Eligibility for CCM and TCM services

The CCM and TCM programs were created to provide reimbursement for services to Medicare recipients who have health needs not included within standard Medicare coverage. Medicare recipients who have two or more chronic conditions that are expected to last at least 12 months—or until the patient’s death—and place the patient at significant risk of death, acute exacerbation or decompensation (or both), or functional decline are eligible for CCM services.1 Medicare recipients who are being discharged from an inpatient setting and are returning home or to an assisted living (or similar) facility are eligible for TCM services.2

Providers of CCM and TCM services

Physicians (i.e., MDs and DOs) of any specialty and the following NPPs are considered providers under the CCM and TCM programs and are permitted to furnish and bill for CCM1 and TCM2 services: 

  • Certified nurse-midwives
  • Clinical nurse specialists
  • Nurse practitioners
  • Physician assistants

Only one of these providers is allowed to bill for CCM or TCM services in a calendar month. It is not permissible for both CCM and TCM services to be billed during the same month.

CCM services

CCM services are described by CMS as follows:

CCM service[s are] extensive, including structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the practice. … CCM services are typically provided outside of face-to-face patient visits, and focus on characteristics of advanced primary care such as a continuing relationship with a designated member of the care team; patient support for chronic diseases to achieve health goals; 24/7 patient access to care and health information; receipt of preventive care; patient and caregiver engagement; and timely sharing and use of health information.1

CCM services provided by clinical staff under general supervision

Under Current Procedural Terminology (CPT) code 99490, at least 20 minutes of CCM services per month must be provided by the physician, NPP, or clinical staff who are functioning under the provider’s direction and authority. CPT 99490 allows certain tasks to be performed by clinical staff under general supervision. Note the following CMS statement:

General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required.1

Clinical staff under CCM

Note the following question and answer provided by CMS:

1. The CCM codes describe time spent per calendar month by “clinical staff.” Who qualifies as “clinical staff”? …

Practitioners should consult the CPT definition of the term “clinical staff.” In addition, time spent by clinical staff may only be counted if Medicare’s “incident to” rules are met, such as supervision, applicable state law, licensure, and scope of practice.3

TCM services

The CMS requirements for TCM services include the following:

    • The services are required during the beneficiary’s transition to the community setting following particular kinds of discharges
    • The health care professional accepts care of the beneficiary post-discharge from the facility setting without a gap
    • The health care professional takes responsibility for the beneficiary’s care
    • The beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making

The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days.2

The following two CPT codes cover TCM services. Note that a minimum of one face-to-face visit must be provided within the time frames outlined in these two code descriptions:

    • CPT Code 99495—Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)
    • CPT Code 99496—Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)2

TCM services provided by clinical staff under general supervision

CMS has provided this definition:

Clinical staff under [the provider’s] direction may provide these services, subject to the supervision, applicable state law, and other rules discussed above:

  • Communicate with agencies and community services the beneficiary uses
  • Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living
  • Assess and support treatment regimen adherence and medication management
  • Identify available community and health resources

Assist the beneficiary and/or family in accessing needed care and services2

Clinical staff under TCM

Note the following CMS question and answer:

    • The CPT book describes services by the physician’s staff as “and/or licensed clinical staff under his or her direction.” Does this mean only RNs and LPNs or may medical assistants also provide some parts of the TCM services?

Medicare encourages practitioners to follow CPT guidance in reporting TCM services (see the CPT definition of the term “clinical staff”). Medicare requires that applicable state law, scope of practice and incident to rules must be met in order for a practitioner to bill the MPFS [Medicare Physician Fee Schedule] for TCM services. The practitioner must meet the “incident to” requirements described in Chapter 15 Section 60 of the [Medicare] Benefit Policy Manual 100-02.4

Incident to definition in the Medicare Benefit Policy Manual

Chapter 15, section 60.1, “Incident to Physician’s Professional Services,” of the Medicare Benefit Policy Manual states the following:

Incident to a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness. …

Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. …

Thus, where a physician supervises auxiliary personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician’s service if there is a physician’s service rendered to which the services of such personnel are an incidental part.5

Delegation of CCM and TCM tasks

“Appropriately educated and credentialed medical assistants” meet the Medicare Benefit Policy Manual definition of auxiliary personnel and fall within the CPT definition of clinical staff. For these reasons it is legally permissible for such medical assistants to be delegated by a provider (i.e., a physician or a nonphysician practitioner) some CCM and TCM tasks that are delegable to knowledgeable and competent unlicensed professionals such as medical assistants under state law, and some of the tasks are billable incident to the provider’s services under CPT code 99490 (CCM) or CPT codes 99495 and 99496 (TCM). Also, CCM services provided by such medical assistants may be counted toward meeting the 20-minutes-per-month requirement of CPT code 99490.

Questions? Contact Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org or 800/228-2262.