Chronic Care Management & Risk Adjustment: What Counts, What Doesn’t
This post breaks down CPT 99490, clarifies the face-to-face documentation rule, and offers actionable strategies for compliant coding, provider education, and operational reporting. A must-read for teams navigating value-based care and HCC capture.
ProTrust Billing Partners LLC
11/5/20251 min read
As CMS continues to expand support for Chronic Care Management (CCM), it’s important to understand how these services intersect with risk adjustment—and where the boundaries lie.
What Is CPT 99490?
CPT 99490 covers at least 20 minutes of non–face-to-face care coordination for Medicare patients with two or more chronic conditions. It’s a powerful tool for improving outcomes and reducing avoidable utilization.
Yes, 99490 is a risk adjustment–eligible CPT code.
But that doesn’t mean every diagnosis submitted on a 99490 claim will be accepted for risk adjustment.
The Face-to-Face Requirement Still Applies
CMS requires that all diagnoses used for risk adjustment be documented during a face-to-face encounter with a qualified provider. That means:
Diagnoses submitted on a 99490 claim must have been previously assessed, evaluated, and managed during a face-to-face visit in the same calendar year.
CCM services alone—delivered via phone, portal, or care coordination—do not meet the face-to-face requirement.
Best Practices for Compliance & Capture
To ensure accurate and compliant risk adjustment:
Anchor CCM to a face-to-face visit: Schedule at least one in-person visit annually for all CCM patients.
Document thoroughly: Reference the face-to-face visit in your CCM note and ensure continuity of care is clear.
Audit proactively: Flag 99490 claims without a qualifying visit and educate providers on compliant documentation.
Why It Matters
Accurate risk adjustment ensures appropriate funding for high-need patients and supports the sustainability of value-based care models. CCM is a vital part of that equation—but only when paired with compliant documentation.