Reimbursement
$88.84
Threshold
30m
2026 Status
Active
What is CPT Code 99491?
CPT 99491 is defined as: Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; establishment, implementation, revision, or monitoring of a comprehensive care plan.
This code is primarily used for CCM services. It falls under the category of Care Management / CCM and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.
2026 RVU Components
Relative Value Units (Non-Facility)
Work RVU
1.5
Physician Effort
PE (Non-Fac)
1.09
Practice Expense
Malpractice
0.07
Risk Factor
Total RVU
2.66
Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor
2026 CMS Policy Intelligence
efficiency shield
Strategically exempt from the -2.5% productivity adjustment (Time-based E/M and care management services).
fqhc rhc transition
G0511/G0512 is sunsetted. FQHCs and RHCs must now itemize and bill 99491 directly for 30 minutes of provider-personally provided CCM.
valuation logic
Retains high Work RVU (1.50) reflecting the intensity of provider-level medical decision making compared to staff-led CCM (99490).
Administrative Framework
Place of Service
Key Modifiers
Operational Requirements
minimum time
30 minutes per calendar month
staff type
Strictly Physician or Qualified Health Care Professional (NP, PA, CNS). No clinical staff time counting.
frequency
Once per calendar month
add on codes
99437
care plan requirement
Provider must personally establish, implement, revise, or monitor the comprehensive care plan.
Compliance Checklist
Audit Defense
provider attribution
The medical record must clearly state 'Dr. [Name] personally spent 30 minutes...' to avoid confusion with clinical staff time.
activity verification
Avoid template-driven notes. Document unique clinical insights or decisions made during the time period.
exclusion checks
Ensure no concurrent billing with staff-led CCM (99490) or PCM (99424) for the same patient in the same month.
2026 Update
Medicare's 2026 emphasis on 'Longitudinal Relationships' makes 99491 a premium vehicle for billing direct provider-patient care coordination.
Common Clinical Scenarios
CMS Eligibility: Must have 2 or more chronic conditions. Conditions expected to last 12+ months or until death
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Billing Differentiation
VS 99490
99491 is for 30+ min of PROPER PROVIDER time; 99490 is for 20+ min of clinical staff time under general supervision.
VS 99424
99424 (PCM) is for a single complex condition; 99491 (CCM) requires two or more chronic conditions.
VS 99437
99437 is the add-on code for each additional 30 minutes of provider-personally provided CCM time.
Frequently Asked Questions
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