Medicare Programs
Chronic Care
Management
Non-face-to-face care coordination for patients with multiple chronic conditions.
- Billable monthly — no device required
- Comprehensive care plan coordination
- Multi-provider communication hub
Overview
What Is Chronic Care Management?
CCM provides reimbursement for non-face-to-face care coordination for Medicare patients with two or more chronic conditions. It covers care plan development, medication reconciliation, and provider coordination — billable monthly without any device requirement.
- Billable monthly without device requirement
- Care plan development and revision
- Medication reconciliation and management
- Coordination across multiple providers
Margaret S.
CHF, Hypertension
Robert K.
COPD, Diabetes
Linda T.
Diabetes Type 2
James P.
Post-Surgical
Carol W.
Hypertension
Eligibility
Qualifying Condition Combos
CCM requires patients with two or more chronic conditions expected to last at least 12 months. Below are the most common condition pairings.
2+ chronic conditions required. Each condition must be expected to last at least 12 months and place the patient at significant risk of death, acute exacerbation, or functional decline.
Hypertension + Diabetes
I10E11.xMost common CCM pairing. Overlapping cardiovascular and metabolic risk factors.
Heart Failure + CKD
I50.xN18.xHigh-acuity combo requiring frequent medication and fluid management.
COPD + Heart Failure
J44.xI50.xRespiratory and cardiac comorbidity with frequent exacerbation risk.
Diabetes + CKD
E11.xN18.xProgressive renal disease driven by uncontrolled glucose levels.
Hypertension + CKD
I10N18.xBlood pressure control is critical to slowing renal decline.
Process
How CCM Works
A structured four-step process that turns care coordination into compliant monthly billing.
Identify Eligible Patients
Screen your patient population for Medicare beneficiaries with two or more chronic conditions expected to last at least 12 months.
Obtain Patient Consent
Verbal or written consent documented in the medical record. Inform the patient that only one provider may bill CCM per month and cost-sharing may apply.
Develop Care Plan
Create a comprehensive, person-centered care plan addressing all chronic conditions, medications, and coordination needs across providers.
Monthly Coordination
Deliver non-face-to-face care activities totaling 20+ minutes per month: medication reconciliation, provider coordination, care plan revision, and patient education.
Platform
Care Coordination Dashboard
Track staff activities, monitor time spent on care coordination, and ensure monthly billing thresholds are met — all from a single dashboard.
- Real-time staff activity tracking
- Automated time logging per patient
- Care plan revision alerts
- Multi-provider communication log
0
Tasks Done
0
2-Way Comms
0
Patient Calls
0
Alerts Triaged
0
Clinical Notes
--
Doc Rate
2+
Chronic Conditions Required
20
Minutes Monthly Minimum
3
Billable CPT Codes
$110
Avg Monthly Per Patient
Revenue
CPT Codes & Billing
CCM offers both standard and complex billing tiers, allowing you to bill based on the level of care and physician involvement each patient requires.
Chronic Care Management — First 20 Minutes
Non-face-to-face chronic care management services for patients with two or more chronic conditions expected to last at least 12 months. Covers the first 20 minutes of clinical staff time per calendar month, directed by a physician or other qualified healthcare professional.
Chronic Care Management — Each Additional 20 Minutes
Each additional 20 minutes of clinical staff time for chronic care management beyond the initial 20 minutes billed under 99490. May be billed up to two times per calendar month (for a maximum of 60 total minutes under standard CCM).
Complex Chronic Care Management — First 30 Minutes (Physician-Directed)
Complex CCM services requiring substantial physician or qualified healthcare professional involvement in care management activities. Covers the first 30 minutes of direct physician/QHP time (not clinical staff time) per calendar month. Used when patients require more complex medical decision-making.
Complex Chronic Care Management — Each Additional 30 Minutes
Each additional 30 minutes of physician or qualified healthcare professional time for complex chronic care management in the same calendar month. Must be billed in conjunction with 99491 as the base code.
Estimated Monthly Revenue Range
~$62–$175 per patient per month
CMS Medicare Physician Fee Schedule, CY 2026
Why CCN Health
Built for CCM Success
We handle the complexity so your team can focus on patient care.
No Device Needed
CCM is pure care coordination — no hardware costs, no patient device training, no connectivity troubleshooting. Your team starts billing from day one with zero upfront investment.
Automated Time Tracking
Every minute of care coordination is automatically logged and time-stamped. No manual stopwatches, no guesswork — just accurate, compliant documentation that meets CMS requirements.
Care Plan Templates
Pre-built, condition-specific care plan templates for common chronic disease combinations. Hypertension + diabetes, CHF + CKD — ready to customize and deploy immediately.
Multi-Provider Coordination
Seamless communication across the care team — PCPs, specialists, pharmacies, and home health agencies. Every coordination touchpoint is documented for audit-ready billing.
Medication Reconciliation
Automated medication review workflows that flag interactions, duplications, and adherence gaps. Reconciliation documentation is built into every monthly care cycle.
Audit-Ready Documentation
Every activity is documented and time-stamped automatically. Generate compliance-ready reports for any billing period with a single click — no manual assembly required.
Compliance
Stay Compliant, Avoid Common Pitfalls
CCM billing compliance requires attention to documentation, consent, and time tracking.
Compliance Essentials
- CCM services (99490/99439) can be furnished by clinical staff under general supervision of the billing practitioner
- Complex CCM (99491) requires direct physician or QHP time — clinical staff time does not count toward this code
- Only one practitioner can bill CCM for a given patient per calendar month — practices must coordinate to avoid duplicate billing
- CCM and RPM can be billed concurrently, but time cannot be double-counted between programs
- CCM and PCM should not be billed for the same patient in the same month
- Patient consent can be verbal but must be documented in the medical record with the date obtained
- Care plans must be electronically stored and available to all care team members
Common Mistakes
- Not obtaining and documenting patient consent before billing — consent must be documented in the medical record
- Overlapping CCM time with PCM time for the same patient in the same month — these services are mutually exclusive per CMS guidelines
- Insufficient care plan documentation — the care plan must be comprehensive, addressing all chronic conditions, medications, and coordination needs
- Failing to conduct medication reconciliation as part of CCM services
- Not meeting the 20-minute minimum threshold before billing 99490
- Billing 99491 (complex CCM) with clinical staff time instead of physician/QHP personal time
- Not having an initiating face-to-face visit within the prior 12 months
FAQs
Frequently Asked Questions
Common questions about CCM eligibility, billing, and implementation.
Yes, CCM and RPM can be billed concurrently for the same patient in the same calendar month. The key requirement is that time spent on each service must be tracked separately — you cannot count the same clinical minutes toward both CCM and RPM time thresholds. For example, 20 minutes of care plan coordination counts toward CCM, while 20 minutes of reviewing RPM device data and communicating with the patient counts toward RPM.
Qualifying chronic conditions include any condition expected to last at least 12 months that places the patient at significant risk of death, acute exacerbation, or functional decline. Common qualifying conditions include hypertension, diabetes, heart failure, COPD, chronic kidney disease, depression, and arthritis. The patient must have at least two such conditions to qualify for CCM.
Bill 99491 when the patient's condition complexity requires substantial direct physician or qualified healthcare professional involvement — not just clinical staff oversight. Complex CCM is appropriate when patients need complex medical decision-making, management of multiple interacting conditions, or coordination across multiple specialists. The critical difference is that 99491 requires 30 minutes of physician/QHP personal time, whereas 99490 requires 20 minutes of clinical staff time under general supervision.
CMS does not require annual renewal of CCM consent; once obtained, consent remains valid unless the patient revokes it. However, best practice is to confirm the patient's continued participation at least annually, typically during their Annual Wellness Visit or a comprehensive E/M visit. The initial consent must clearly inform the patient that only one practitioner can bill CCM per month and that cost-sharing may apply.
Qualifying CCM activities include: care plan development and revision, medication reconciliation and management, communication with other treating providers, coordination with home health agencies or community services, patient or caregiver education, and assessment of psychosocial needs. Time spent on administrative tasks like scheduling or billing does not count. All activities must be documented with date, duration, and description.