Chronic care management services, personal care plan oversight, 30 minutes per month
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. 30-minute time requirement by physician/QHP not met
Very Common99491 requires 30+ minutes of complex CCM by physician or qualified health professional. Denials occur when time doesn't reach 30 minutes or is performed by non-qualifying staff.
Common Causes
- • Time log shows <30 minutes
- • Services performed by RN or medical assistant (not QHP)
- • No documentation of physician/QHP involvement
Resolution Strategy
Provide time log showing 30+ minutes of physician or QHP time on complex CCM activities. Must clearly identify which provider performed services.
💬 Plain Language Explanation
What this means
This is complex chronic care management - more intensive care coordination for patients with multiple serious chronic conditions. Your doctor's office spent significant time (at least 60 minutes) coordinating your complex care.
Why you might see this
This code is used when your doctor provides intensive care management for complex chronic conditions. It requires at least 60 minutes of care coordination per month and is for patients with more serious or complex conditions.
Common context
Used for patients with complex, multiple chronic conditions requiring intensive care coordination (60+ minutes per month).
What to ask your provider
"'What made my care management complex? How much time was spent on care coordination?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
Physician personally provides at least 30 minutes of chronic care management services per month
Common Scenarios
Documentation Requirements
- 2+ chronic conditions documented
- Physician personally provided at least 30 minutes
- Comprehensive care plan
- 24/7 access documented
- Time log showing physician's personal involvement
- Patient consent obtained
Coding Guidelines
Bundling Rules
- Cannot bill with 99490 or 99487 same month
- Requires physician personally provide services (not clinical staff)
Exclusions
- Do not bill if clinical staff provided services (use 99490 instead)
- Cannot bill in same month as other CCM codes
Coding Notes
Clinical scenarios
- 2+ chronic conditions documented
- Physician personally provided at least 30 minutes
- Comprehensive care plan
- 2+ chronic conditions documented
- Physician personally provided at least 30 minutes
- Comprehensive care plan
- 2+ chronic conditions documented
- Physician personally provided at least 30 minutes
- Comprehensive care plan
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Code Details
Medicare Pricing
PFSRVU Breakdown
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Frequently Asked Questions
CPT 99491 is the billing code for "Chronic care management services, personal care plan oversight, 30 minutes per month". Physician personally provides at least 30 minutes of chronic care management services per month
Medicare pays approximately $82.16 for CPT 99491 (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 99491 has a total RVU of 2.14, broken down as: Work RVU 0.00, Practice Expense RVU 2.14, and Malpractice RVU 0.00. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99491 is "30-minute time requirement by physician/QHP not met". 99491 requires 30+ minutes of complex CCM by physician or qualified health professional. Denials occur when time doesn't reach 30 minutes or is performed by non-qualifying staff. Common causes include: Time log shows <30 minutes; Services performed by RN or medical assistant (not QHP). Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99491 include: 2+ chronic conditions documented; Physician personally provided at least 30 minutes; Comprehensive care plan; 24/7 access documented. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99491: Cannot bill with 99490 or 99487 same month. Requires physician personally provide services (not clinical staff) Use an NCCI bundling checker to verify specific code combinations before billing.
The typical time requirement for CPT 99491 is Minimum 30 minutes by physician personally per month. Time-based codes require documentation of the actual time spent providing the service.