Complex chronic care management services, first 60 minutes
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Complex CCM time below 60-minute threshold or qualifying criteria not met
Very Common99487 (complex chronic care management) requires: (1) 60+ minutes monthly time, (2) moderate/high complexity medical decision-making, AND (3) care plan for 3+ chronic conditions. Standard CCM (99490) requires only 20 min/month. Payers scrutinize 99487 heavily due to 3x higher reimbursement. Must document all three criteria - missing any one triggers denial.
Common Causes
- • Monthly time 55 minutes - below 60-minute threshold, should bill 99490 + 99439 instead
- • Only 2 chronic conditions in care plan - need 3+ for complex CCM
- • Low complexity problems (stable hypertension, GERD) - need moderate/high complexity MDM
Resolution Strategy
Document all three complex CCM criteria: (1) Time log showing 60+ minutes monthly CCM activities, (2) Moderate/high complexity MDM with 3+ chronic conditions requiring active management (e.g., CHF with recent exacerbation, diabetes with medication changes, COPD with home oxygen), (3) Comprehensive care plan addressing all conditions with goals, medications, specialists, barriers to adherence. Appeal with documentation showing all criteria met. If time 20-59 min, rebill as 99490 + appropriate 99439 units instead.
Relative Value Units (RVUs)
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Clinical Information
When to Use
Monthly complex chronic care management requiring 60+ minutes for patients with multiple serious chronic conditions
Common Scenarios
Documentation Requirements
- Comprehensive care plan addressing all chronic conditions
- Time spent on CCM activities documented (60+ minutes)
- Moderate or high complexity medical decision making documented
- Care coordination with specialists and other providers
- Patient/caregiver communication documented
Coding Guidelines
Common Modifiers
Bundling Rules
- Cannot be billed same month as 99490, 99439 (non-complex CCM)
- Requires two or more chronic conditions with high risk complications
- Requires moderate or high complexity MDM
- Can be billed with 99489 for additional time
Exclusions
- 99490-99491 (non-complex CCM or principal care management)
- 99484 (behavioral health integration; different service)
- 99358-99359 (prolonged non-face-to-face; different purpose)
Coding Notes
Clinical scenarios
- Comprehensive care plan addressing all chronic conditions
- Time spent on CCM activities documented (60+ minutes)
- Moderate or high complexity medical decision making documented
- Comprehensive care plan addressing all chronic conditions
- Time spent on CCM activities documented (60+ minutes)
- Moderate or high complexity medical decision making documented
- Comprehensive care plan addressing all chronic conditions
- Time spent on CCM activities documented (60+ minutes)
- Moderate or high complexity medical decision making documented
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Code Details
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Frequently Asked Questions
CPT 99487 is the billing code for "Complex chronic care management services, first 60 minutes". Monthly complex chronic care management requiring 60+ minutes for patients with multiple serious chronic conditions
Medicare pays approximately $131.65 for CPT 99487 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99487 has a total RVU of 4.29, broken down as: Work RVU 2.61, Practice Expense RVU 1.52, and Malpractice RVU 0.16. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99487 is "Complex CCM time below 60-minute threshold or qualifying criteria not met". 99487 (complex chronic care management) requires: (1) 60+ minutes monthly time, (2) moderate/high complexity medical decision-making, AND (3) care plan for 3+ chronic conditions. Standard CCM (99490) requires only 20 min/month. Payers scrutinize 99487 heavily due to 3x higher reimbursement. Must document all three criteria - missing any one triggers denial. Common causes include: Monthly time 55 minutes - below 60-minute threshold, should bill 99490 + 99439 instead; Only 2 chronic conditions in care plan - need 3+ for complex CCM. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99487 include: Comprehensive care plan addressing all chronic conditions; Time spent on CCM activities documented (60+ minutes); Moderate or high complexity medical decision making documented; Care coordination with specialists and other providers. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99487: Cannot be billed same month as 99490, 99439 (non-complex CCM). Requires two or more chronic conditions with high risk complications Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99487 include: None typically required (Standalone monthly service). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99487 is Minimum 60 minutes of complex CCM services per calendar month. Time-based codes require documentation of the actual time spent providing the service.