CCM is for patients that:

• Are expected to last at least 12 months (or until death),
• Place the patient at significant risk of death, hospitalization, acute exacerbation/decompensation, or functional decline,
• Require an ongoing, comprehensive care plan and regular management between office visits.

Think of CCM as the “multi‑condition” version of PCM, which applies to a single serious chronic condition.

📋 CCM RequirementsTo bill CCM under CPT codes 99490, 99439, 99491, 99437, 99487, 99489, the following elements must be met:

1) Initiating Visit (CMS)

• A face‑to‑face initiating visit (AWV, IPPE, or E/M) is required for new patients or those not seen within the past 12 months.

“We require an initiating visit before you start CCM services.” (CMS, MLN909188)

2) Patient Eligibility (CMS)

• Patient has two or more chronic conditions expected to last ≥12 months or until death, at significant risk of exacerbation or decline.

“CCM is managing a patient’s multiple (2 or more) chronic conditions expected to last at least 12 months … at significant risk of death, acute exacerbation or decompensation, or functional decline.” (CMS, MLN909188)

3) Time Thresholds (CMS)

• Count per calendar month time spent on CCM activities.
  • 99490: First 20 minutes of clinical staff time (under general supervision).
  • +99439: Each additional 20 minutes of staff time.
  • 99491: First 30 minutes of physician/QHP time (personally performed).
  • +99437: Each additional 30 minutes of physician/QHP time.
  • 99487: First 60 minutes of complex CCM (moderate/high medical decision-making).
  • +99489: Each additional 30 minutes of complex CCM.
  “You can’t bill for CCM services of less than the required 20 or 30 minutes per calendar month.” (CMS)

4) Comprehensive Care Plan (AMA/CMS)

• Create, revise, and monitor a patient‑centered electronic care plan that includes problem list, prognosis, measurable goals, symptom management, interventions, medication management, and caregiver input.

“Establishment, implementation, revision, or monitoring of a comprehensive care plan.” (AMA CPT® descriptor)

5) Medication Management (AMA)

• Review, reconcile, and adjust medications regularly; ensure adherence and address side effects.

“Medication self‑management and oversight, including potential interactions and monitoring.” (AMA)

6) Communication & Coordination (AMA vs CMS)

We encourage at least one two‑way communication with the patient or caregiver each month for CCM.

“Ongoing communication and care coordination with the patient/family/caregiver and other treating health professionals.” (AMA)

• AMA requires communication and coordination as a core service element.
• CMS MLN materials describe 24/7 access, patient/caregiver engagement, and ways to communicate (phone, secure portal, email), but do not explicitly state “one two‑way communication per month.”
• CCN Health applies the conservative AMA‑based standard.

Acceptable forms of communication include:

• Phone calls with patient/caregiver
• Video or telehealth check‑ins
• Secure portal messaging (with response)
• In‑person contact outside of E/M visits
• Provider‑to‑provider communication (documented and relayed to patient)

7) Billing Restrictions (CMS)

• Only one practitioner can bill CCM for a patient per calendar month.
• CCM cannot be billed concurrently with PCM by the same practitioner for the same patient in the same month.

“Only 1 practitioner can provide and bill CCM services during a calendar month.” (CMS, MLN909188)

8) Frequency (CMS)

• Bill monthly, as long as time and service elements are met.

“You may provide CCM services monthly, as medically necessary.” (CMS)

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