Billing & Eligibility
ICD-10 Qualifying
Diagnosis Directory.
Look up ICD-10 codes that qualify your patients for Medicare care management programs. Filter by program, medical specialty, or diagnosis category to find eligible conditions for RPM, CCM, PCM, BHI, and RTM.
Interactive Directory
Search qualifying diagnoses.
Filter by Medicare program, medical specialty, or diagnosis category. Search by ICD-10 code or condition name.
Frequently Asked Questions
ICD-10 eligibility questions.
What ICD-10 codes qualify patients for RPM?
RPM qualifying diagnoses include any condition with a measurable physiologic parameter that can be monitored via an FDA-cleared device. Common qualifying ICD-10 codes include I10 (essential hypertension), E11.65 (type 2 diabetes with hyperglycemia), I50.9 (heart failure), J44.1 (COPD with exacerbation), N18.30 (CKD stage 3), and G47.33 (obstructive sleep apnea). RPM requires only one qualifying condition with no minimum duration.
How many chronic conditions are required for CCM?
CCM (Chronic Care Management) requires at least two chronic conditions expected to last 12 months or longer that place the patient at significant risk of death, acute exacerbation, or functional decline. Common qualifying condition pairs include hypertension + diabetes, heart failure + CKD, COPD + depression, and diabetes + obesity.
What is the difference between PCM and CCM qualifying diagnoses?
PCM (Principal Care Management) focuses on a single high-risk chronic condition expected to last at least 3 months, while CCM requires two or more conditions lasting 12+ months. PCM is ideal when one dominant condition drives the majority of care needs — such as uncontrolled heart failure or poorly controlled diabetes. PCM and CCM cannot be billed for the same patient in the same month.
Which ICD-10 codes qualify for BHI (Behavioral Health Integration)?
BHI qualifying diagnoses include behavioral health conditions such as F32.x (major depressive disorder), F41.1 (generalized anxiety disorder), F43.10 (PTSD), F31.x (bipolar disorder), F10.20 (alcohol dependence), and F11.20 (opioid dependence). BHI services use validated screening tools like PHQ-9 and GAD-7 for ongoing assessment.
What conditions qualify for RTM (Remote Therapeutic Monitoring)?
RTM covers musculoskeletal and respiratory conditions requiring ongoing therapeutic monitoring. Qualifying ICD-10 codes include M17.x (knee osteoarthritis), M54.5 (low back pain), M79.7 (fibromyalgia), J44.x (COPD), and J45.x (asthma). Unlike RPM which tracks vital signs, RTM monitors therapy adherence, pain levels, and functional status.
Can a patient qualify for multiple Medicare care management programs simultaneously?
Yes. A patient can receive RPM, CCM, BHI, and RTM simultaneously, provided each service addresses distinct clinical needs with separate time documentation. However, PCM and CCM cannot be billed in the same month for the same patient. For example, a patient with heart failure (RPM), diabetes + hypertension (CCM), and depression (BHI) can generate over $330 per month across all three programs.