Chronic Care Management

CCM: Consistency That Drives Better Care

  • Earn monthly reimbursements per patient

  • Improve outcomes with proactive care coordination

  • Offload your team with our white-labeled solution

CCM

What Is Chronic Care Management (CCM)?

Chronic Care Management (CCM) is a Medicare program that supports patients with two or more chronic conditions. CCM helps healthcare providers deliver ongoing, coordinated care between office visits—improving patient outcomes and increasing revenue for your practice.
  • Who is CCM for? Patients with two or more chronic conditions expected to last at least 12 months (such as diabetes, heart disease, or COPD) are eligible for CCM services.
  • Why is it great for patients?  Patients receive consistent, personalized follow-up and support between doctor visits. This leads to better medication adherence, fewer hospitalizations, and improved overall outcomes.
  • Why is it great for practices? Practices strengthen patient relationships, improve care continuity, and are reimbursed for work they already do—such as care coordination, follow-ups, and outreach.
How It Works (In Plain English)
Your patient has two or more chronic conditions—things like diabetes, hypertension, or arthritis.
Each month, your staff spends 20+ minutes coordinating their care: phone check-ins, medication refills, scheduling, follow-ups.

Our platform logs the time, tracks every task, and makes sure it's audit-proof. At the end of the month, you bill Medicare and get paid.

No device needed. Just your team, the patient, and our software keeping it all organized.
Vitals You Can Monitor
Blood Pressure Monitor
Thermometer
Weight Scale
Caregiver app
Clinical Surveys
GCMs
Glucose Monitor
Pulse Oximeter
Sleep Analyzer
Smart Pillbox
See Devices

Chronic Care Management Codes

CPT 99439

(

~$45

)

Additional 20 minutes – non‑complex (add‑on)

Additional 20 Minutes of Non‑Complex CCM

This add-on code is for each extra 20‑minute block (beyond the initial 20 under 99490) of non-complex CCM services in the same month.

CPT 99487

(

~$133

)

60‑minute clinical staff time – complex

Initial 60 Minutes of Complex CCM

This code covers at least 60 minutes of chronic care management for patients with complex conditions requiring moderate-to-high medical decision-making, provided by clinical staff under physician or advanced practitioner supervision in a calendar month.

CPT 99489

(

~$47

)

Additional 30 minutes – complex (add‑on)

Additional 30 Minutes of Complex CCM

This add-on code covers each extra 30‑minute increment of complex CCM services beyond the initial 60 in the same calendar month.

CPT 99490

(

~$60

)

20‑minute clinical staff time – non‑complex

Initial 20 Minutes of Non‑Complex CCM

This is billed when clinical staff, under physician or advanced practitioner supervision, provides at least 20 minutes of non-complex chronic care management services in a calendar month.

Increase your revenue today

CPT 99439
(
~$45
)
Additional 20 minutes – non‑complex (add‑on)
This add-on code is for each extra 20‑minute block (beyond the initial 20 under 99490) of non-complex CCM services in the same month.
CPT 99487
(
~$133
)
60‑minute clinical staff time – complex
This code covers at least 60 minutes of chronic care management for patients with complex conditions requiring moderate-to-high medical decision-making, provided by clinical staff under physician or advanced practitioner supervision in a calendar month.
CPT 99489
(
~$47
)
Additional 30 minutes – complex (add‑on)
This add-on code covers each extra 30‑minute increment of complex CCM services beyond the initial 60 in the same calendar month.
CPT 99490
(
~$60
)
20‑minute clinical staff time – non‑complex
This is billed when clinical staff, under physician or advanced practitioner supervision, provides at least 20 minutes of non-complex chronic care management services in a calendar month.
A Nurse taking care of a patient

Why Choose CCN Health?

Instant EHR Integration

Automatically sync patient data directly into your existing workflow—no manual entry required.

Transparent Billing Guidance

Know exactly what CPT codes apply, why they apply, and how to maximize your reimbursements.

Rapid Onboarding

Go from discovery to billing within a single week. No delays, no hassles.

Zero Risk & No Cost

All devices, training, and integration are completely free. You pay nothing upfront.

🚀 6-Step “Quick-Launch” Framework
Understanding the process
01

Discovery Call

We review your chronic care population, revenue opportunities, and determine how CCM can best support your practice.

02

Sign BAA & Begin Setup

After BAA execution, we activate your CCM environment, integrate your EHR, and prepare customizable care plan templates.

03

Identify & Enroll Eligible Patients

We generate eligibility reports, help you select a pilot cohort, and send patients digital consent via text or email.

04

Launch CCM Workflows

Care plans, monthly touchpoints, and time tracking go live in CCN Health, enabling structured and repeatable CCM processes.

05

Workflow Customization & Team Training

In a single 45‑minute session, your team learns how to manage CCM tasks, document billable time, and streamline monthly outreach.

06

Start Billing With Confidence

Your dashboard clearly shows completed minutes, eligible codes, and all documentation needed for compliant CCM billing.

How to Use CCN Health Software for a Month of Chronic Care Management (CCM)

Throughout the entire process, our software automatically tracks time and captures notes—you can manually add additional notes and time entries at any point.

1. Check Patient Goals

Check Patient Goals

2. Update Chronic Conditions

Update Chronic Conditions

3. Patient Interaction

  • Clinical screenings and surveys:  PHQ-9, GAD-7, Falls Risk, etc.
Clinical screenings and surveys:  PHQ-9, GAD-7, Falls Risk, etc.

4. Doctor Review & Finalization

Doctor Review & Finalization

5. Generate Audit-ready Report

Ready to Start?
Schedule your quick, no-obligation discovery call today—and start billing CCM, RPM, RTM, PCM, or BHI within your first 30 days.